PLAN EFFECTIVE DATE: February 1, 1990
SERVICE WAITING PERIOD: None
EMPLOYEES' ELIGIBLE: All employees who are members of the Arlington Teachers' Association Bargaining Unit
DEPENDENTS ELIGIBLE: All dependents as defined.
NON-CONTRIBUTORY DENTAL BENEFITS FOR YOU AND FOR YOUR DEPENDENTS: Maximum Dental Benefit (per calendar year) $2,750
IMPORTANT:Read this document carefully. See "Plan Exclusions" and "General Information" for other conditions that may affect coverage.
You will be eligible on the first day of the month following your date of employment, provided the enrollment is completed through the Welfare Trust. The Plan Effective Date is listed in the Schedule of Benefits.
If you are not actively at work on the day you would normally become eligible, you will be eligible on the day you return to active work.
DEPENDENT
This term means:(a) your spouse/domestic partner. Your spouse must not be legally separated from you.
(b) each of your single children. The term "children" also includes any other single child if that child lives in your household in a parent-child relationship and is dependent on you for support.
Each child must be under age nineteen, or a full-time student under age twenty-five.
If your child is mentally ill, developmentally disabled or mentally retarded or has a physical handicap when coverage would end due to the child's age, insurance may be continued. Ask the Trust Fund within thirty-one days of the date your child's insurance ends for details and forms.
BECOMING ELIGIBLE
Each person who is your dependent on the day you become eligible for coverage is eligible on that day. Each other person is eligible on the day that person becomes your dependent.
BECOMING COVERED
A wife or husband who is eligible for coverage under this plan as an employee may also be eligible as a dependent. In addition, if both you and your spouse are covered under this plan as employees, your children may be covered as dependents of both you and your spouse. Your dependent will be covered on the day they become eligible.
Except for a child at birth, a dependent confined to a hospital or other covered institution when that person's coverage would normally begin will be covered on discharge.
Your dependents will not be covered before the day your coverage begins.
WHEN ARE BENEFITS PAYABLE
Benefits are payable for Covered Dental Charges incurred while the person is covered for these benefits. These charges must be due to a disease, defect or accidental injury to teeth covered by these benefits.
WHAT ARE COVERED DENTAL CHARGES
Covered Dental Charges are charges incurred for any service or supply included in the Schedule of Dental Procedures. A detailed list of common procedures and the maximum amount for each procedure appear at the end of this document. Covered Dental Charges do not include part of any such charge, which exceeds the maximum amount shown in the Schedule of Dental Procedures.
Preventive Services and Supplies
A cleaning and scaling of teeth (prophylaxis) is limited to one service in a six-month period. (This limit includes periodontal prophylaxis')
Space maintainers and their fitting. (These are appliances used to keep teeth from moving into the space left when a tooth is pulled or lost).
Fluoride treatment
Fissure sealants
Diagnostic and Therapeutic Services
Full mouth and panoramic X-rays are limited to one for either type of X-ray in three
calendar years.
Bitewing X-rays are limited to one series (4 bitewing x-rays) in a six-month period.
Diagnostic oral examinations\evaluations are limited to one service in a six-month period.
Emergency treatment for relief of dental pain (only covered on a day when no services other
than Dental X-rays are provided).
Extractions and cutting procedures in the mouth (oral surgery).
Treatment of jaw, fractures and dislocations are also covered.
(Extra charges for removing stitches and exams after surgery are not covered).
Treatment of gums and supporting structure of the teeth.
Root canal therapy (endodontic treatment).
General anesthetics for oral surgery, fractures, dislocations and treatment of gums.
Antibiotic drugs which are injected by a dentist or physician.
Bacteriologic studies
Diagnostic casts
Diagnostic photos
Restorative Services and Supplies
Fillings and crowns to repair a tooth containing decay or damaged due to injury.
Charges for these restorations are limited to a charge for silver, porcelain or other filling unless the tooth cannot be repaired with a less expensive filling. If the tooth can be repaired by a less expensive method, only that charge will be covered.
Charges for replacement crown and gold fillings are covered only if the old crown or filling is over five years old.
Prosthetic Services and Supplies
Full or partial dentures and fixed bridges to replace missing natural teeth. The teeth that are being replaced must be lost while the person is covered. Full or partial dentures and fixed bridges to replace an existing denture or bridge that cannot be made serviceable.
The existing denture or bridge must be over five years old.
Repair and re-basing of existing dentures which have not been replaced by a new denture.
Covered charges for both a temporary and permanent prosthesis will be limited to the charge for the permanent one.
HOW MUCH CAN I BE REIMBURSED
Each covered person can be reimbursed for Covered Dental Charges incur-red in a calendar year up to the maximum shown in the Schedule of Benefits.
If Covered Dental Charges for any course of treatment are expected to be more than $300 and you wish an estimate of any benefits that would be payable, you may send the Plan Coordinator a treatment plan. This plan is a doctor's written report giving the results of the doctor's exam of the insured person and the suggested treatment.
The estimate is based on dental necessity only and does not take into account any maximums that may apply. You are subject to your plan maximums regardless of any pre-estimate you may receive.
WHEN IS A CHARGE INCURRED
A charge is incurred on:
(a) the date the impression is taken, in the case of dentures or fixed bridges.
(b) the date the preparation of the tooth is begun, in the case of crown work.
(c) the date the work on the tooth is begun, in the case of root canal therapy.
(d) the date the work is done, in the case of any other work.
PLAN EXCLUSIONS
Covered Dental Charges do not include charges for services and supplies:
(a) that are not ordered by a dentist or doctor.
(b) which do not meet the standard set by the American Dental Association.
(c) that are provided in a Veteran's Administration Hospital.
(d) which a covered person would not legally have to pay if there were no coverage.
(e) that are due to war, if declared or not.
(f) that are for cosmetic reasons.
(g) for orthodontic appliances and treatment other than for related extractions or space maintainers.
(h) for facings on pontics or crowns posterior to the second bicuspid.
(i) for oral hygiene, dietary, plaque control and other educational programs.
for procedures, restorations and appliances that increase vertical dimension or restore occlusion.
(k) for an injury or sickness due to employment with any employer or self-employment.
(l) that are furnished in a U.S. government hospital.
(m) which a Dependent is entitled to benefits as an employee or former employee of the Plan holder.
(n) for special techniques or precision attachments.
(o) for any special work that you ask to have performed on a standard denture.
(p) for adjustments during the first six months a denture is installed.
IMPORTANT: See "General Information" for other conditions that may affect this coverage.
For any dental procedure not shown in the Schedules of Dental Procedures, the Plan Coordinator will determine an allowance consistent with the amounts appearing in said Schedule.
GENERAL INFORMATION
DEFINITIONS
Trust Fund Any reference in this booklet to the Trust Fund means The Arlington Teachers' Association Welfare Trust Fund.
Plan Coordinator Refers to Preferred Group Plans, Inc.
Active Work/Actively At Work This term means the performance of all the duties that pertain to your work at the place where it is normally report, or where it is required by the Trust Fund.
Doctor
The term "Doctor" means a dentist or a physician. The term:
(a) "dentist" means a Doctor of Dental Surgery or a Doctor of Medical Dentistry.
(b) "physician" means legally licensed to practice medicine and surgery.
Charges/Fees/Expenses The terms "chargee, "fees", or Coexpenses", as they relate to
health care, will not include any amount:
(a) for a service or supply, which is not medically necessary, even if ordered by a doctor.
Medically Necessary. This term means services or supplies which, as determined by the
Plan Coordinator are: (i) provided for the diagnosis or treatment of a medical condition;
(ii) proper for the symptoms, diagnosis or treatment of a medical condition; (iii) performed in
the proper setting or manner required for a medical condition; and (iv) within the standards
of generally accepted health care practice.
(b) for a service or supply which is provided only as a convenience, even if ordered by a doctor.
(c) for repeated tests which are not needed, even if ordered by a doctor.
(d) more than what is reasonable and customary in the locale where incurred, as determined by
the Plan Coordinator and as elected by the Trust Fund.
The Plan Coordinator will determine these amounts.
NON-DUPLICATION OF BENEFITS
If a covered person is entitled to benefits for dental care under this Plan and at least one other plan, the amount of benefits provided by this Plan, if this Plan is the Secondary Plan, may be reduced to the extent that the total benefits paid by all plans during a Claim Determination Period are not more than the total of the Allowable Expenses that the person incurs in that period. The amount by which the Secondary Plan's benefits have been reduced shall be used by the Secondary Plan to pay the stated percentage of Allowable Expenses, not otherwise paid, which were incurred during the Claim Determination Period by the person for whom the claim is made. As each claim is submitted, the Secondary Plan determines its obligations to pay for the stated percentage of Allowable Expenses based on all claims which were submitted up to that point in time during the Claim Determination Period.
This will be done as set forth in Order of Payment.
ALLOWABLE EXPENSES
This term means any necessary, reasonable and customary item of expense a part of the cost of which is covered by (a) this Plan, or (b) one of the other plans, except Medicare or a "no-fault" motor vehicle plan.
When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered as both an Allowable Expense and a benefit paid.
The difference between the cost of a private hospital room and the cost of a semi-private hospital room will not be deemed to be an Allowable Expense; but it will be deemed to be an Allowable Expense only during the period of time the patient's confinement to a private hospital room is deemed necessary as generally accepted in health care practice.
CLAIM DETERMINATION PERIOD
This term means the time during any one plan year when a person is covered and incurs charges for one or more items of expense covered under: (i) this plan; and (ii) at least one other plan.
As each claim is submitted, each Plan is to determine its liability and pay or provide benefits based upon Allowable Expenses incurred to that point in the Claim Determination Period. But that determination is subject to adjustment as later Allowable Expenses are incurred in the same Claim Determination Period.
PLAN
This term means any plan that provides medical or dental care coverage written on an expense incurred basis with which coordination is allowed.
"Plan" may include:
(a) any group insurance, or any other method of coverage for persons in a group.
(b) an insured arrangement of group coverage.
(c) group coverage through HMOs and other prepayment, group practice and individual practice
plans.
(d) any governmental plan, but not including a state plan under Medicaid.
(e) any plan required by law, but shall not include a law or plan when, by law, its benefits are
excess to those of any private insurance plan or other non-governmental plan.
(f) the medical benefits coverage in group and individual mandatory automobile "no-fault" and
traditional mandatory automobile "fault" type contracts.
"Plan" shall not include:
(a) blanket school accident coverage; or (b) hospital indemnity coverage.
THIS PLAN
This term means that part of the Group Plan, which provides benefits for dental care.
PRIMARY PLAN
This term means This Plan, or any other Plan, which determines its medical or dental care benefits for a covered person without taking into account any other Plan. A Plan is Primary if either:
(1) the Plan does not have a Non-Duplication of Benefits provisions like This Plan; or (ii) the Plan, in accord with Order of Payment, would determine its benefits first.
SECONDARY PLAN
This term means any plan, which is not a Primary Plan.
ORDER OF PAYMENT
When a person is covered under two or more plans, the rules that follow will decide the order in
which the plan will pay benefits:
1 . A plan, which does not have a provision like this Non-Duplication of Benefits, will pay
before this Plan.
2. A plan which covers a person other than as a dependent will pay before a plan which covers a
person as a dependent.
3. A plan which covers a person as a dependent of a person whose date of birth occurs earlier in
a calendar year will pay before a plan which covers the person as a dependent of a person
whose date of birth occurs later in a calendar year provided that;
(a) if said dates of birth are the same, the plan that has covered a person for the longest
time will pay first.
(b) if the other plan does not have the rule described above, but instead has a rule based
upon the gender of the parent, and if, as a result, the Plans do not agree on the order of
benefits, the rule in the other plan will determine the order of benefit.
In item 3, above, date of birth means day and month of birth. It does not mean year of birth.
If the person is a dependent child of divorced or separated parents, the order will be as follows:
(a) first, the plan of the parent with custody of the child;
(b) then, the Plan of the spouse of the parent with custody of the child;
(c) finally, the Plan of the parent not having custody of the child.
However, if there is a court decree which sets forth a financial duty for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or plan year during which any benefits are actually paid or provided before the entity has the actual knowledge.
4. The benefits of a plan which covers a person as an employee who is neither laid-off nor
retired (or as that person's dependent) are determined before those of a plan which covers
such person as a laid-off or retired employee (or as that person's dependent).
5. If these four rules do not decide which plan will pay its benefits first, the plan which
has covered the person for the longest time will pay first. The length of time a person has
been covered under a Plan is determined by the following:
(a) Two plans shall be treated as one if the claimant was eligible under the second within 24
hours after the first ended.
(b) The claimant's length of time covered under a Plan is measured from the claimant's first
date of coverage under that Plan. If that date is not readily available, than it is measured
from the date the claimant first became a member of the group.
To administer claims, the Plan Coordinator, without the consent of any person, has the right:
(a) to give or to get any data needed to determine benefits under this provision; and each person
claiming benefits under a Plan must give the Plan Coordinator any data needed to pay the
claim.
(b) to reimburse an organization for a payment made under its Plan, which should have been
paid by the Plan Coordinator. Such amounts paid will be deemed as benefits paid under this
Plan; and to the extent so paid there will be no more liability under this Plan. The term
"payment made" includes providing benefits in the form of services, in which case "payment
made" means reasonable cash value of the benefits provided in the form of services.
(c) to recover any excess if the amount paid is more than it should have paid under this provision
from one or more of
(i) The persons it has paid or for whom it has paid;
(ii) Insurance companies; or
(iii) Other organizations.
A Secondary Plan which provides benefits in the form of services may recover the reasonable cash value of providing the services from the Primary Plan, to the extent that benefits for the services are covered by the Primary Plan and have not already been paid or provided by the Primary Plan. Nothing in this provision shall be interpreted to require a Plan to reimburse a covered person in cash for the value of services provided by a Plan which provides benefits in the form of services.
WHEN COVERAGE ENDS
Your coverage ends at the earliest of the following events:
1. on the last day of the month during which your employment ends. For coverage purposes, your employment is ended when you leave the district's employ, but your coverage continues if you are an active A.T.A member and pay the appropriate dues and fees.
2. when the Group Plan ceases.
3. when your Employer ceases to make contributions to the Trust Fund.
A dependent's coverage ends when any of the following events occurs:
1. such person becomes covered as an employee.
2. that dependent is no longer an eligible dependent.
RETIREES
Prior to 1984 retirees are not eligible for benefits provided through the Welfare Trust. Retirees from 1984 to the present are eligible for Welfare Trust benefits as an active member of the Arlington Teachers' Association. All other retirees from 1984 to the present may join the Welfare Trust if the retiree maintains membership in the Arlington Teachers' Association and pays the required fee as determined by the Trust.
A retiree who elects not to join the Welfare Trust is not eligible to join at a later date.
PAID LEAVE
Active members of the Arlington Teachers' Association are eligible for Welfare Trust benefits.
UNPAID LEAVE
Active member of the Arlington Teachers' Association may be eligible for Welfare Trust benefits. Contact the Welfare Trust Fund for information.
If you cease active work, ask the Trust Fund if arrangements may be made to continue coverage.
If you die while covered, group dental coverage for your covered dependents may be continued for up to one year after your death. Coverage may be extended through the Cobra provision noted below. If your spouse remarries before the end of that year, the coverage for your covered dependents will end when he or she remarries.
COBRA
On April 7, 1986 the Consolidated Omnibus Reconciliation Act (COBRA) of 1985 was signed into law. The provisions of the federal law are outlined below
OPTIONAL CONTINUANCE OF DENTAL COVERAGE
Special Continuance of Employee and Dependent Coverage
If your coverage ends, you may elect to continue for a maximum period of eighteen months the dental Coverage under the Group Plan for you and your dependents, provided that the coverage ends due to:
(a) lay-off,
(b) voluntary termination of employment with your Employer; or
(c) discharge from your employ (other than gross misconduct).
The Preferred Group, Inc. will notify you of your right to continue coverage within 45 days of the occurrence of an above event.
Special Continuance of Dependent Coverage
If your dependent's coverage ends, he or she may elect to continue for a maximum period of thirty six months the Dental coverage under the Group Plan for him or her, as follows:
(a) Your dependent spouse may elect to continue coverage on his or her own behalf and on that of any dependent children whose coverage would otherwise end, provided that the coverage ends due to: (i) your death; or (ii) your divorce or legal separation.
(b) Your dependent child whose coverage would otherwise end, may elect to continue coverage on his or her own behalf, provided that the coverage ends due to the death of the employee when there is no surviving parent, or the child's marriage or attainment of the age limit.
You and your dependent must notify the Welfare Trust of the occurrence of the events shown in (a) (ii) or (b) above. The notice should be given to the Trust as soon as is reasonably possible after the date the event occurred.
Within 45 days of receipt of notice that an event ending in a dependent's coverage has occurred, The Preferred Group, Inc., Inc. shall send notice to your dependent of the right to continue the coverage.
To continue coverage, you or your dependent must apply in writing to The Preferred Group, Inc., Inc. within 60 days of the later of (1) the date the coverage ends; and (2) the date you or your dependent receive notice of the right to continue the coverage.
You or your dependent must pay the required amount if any, for the continued coverage. The Preferred Group, Inc. will inform you of the monthly amount to be paid. You or your dependent must also pay such amount for any period of continued coverage which began prior to the election of such continuance. This amount must be paid within 45 days after the date the continued coverage is elected.
The continued coverage will begin on the date after the date coverage would have ended. It will end when the first of the following events occurs:
(a) the Group Plan terminates:
(b) the end of the period allowed for continued coverage;
(c) the end of the period for which contributions were paid;
(d) the date you or your dependent become covered under a group plan;
(e) the date you or your dependent become eligible for Medicare;
(f) the date your former spouse remarries and thereby becomes covered under a group plan.
DENTAL INSURANCE
Upon receipt of due proof of claim, Dental benefits are payable you.
Benefits payable under your dental expense coverage for covered services may be assigned by you to the provider who performed the service.
Notice of Claim: Written notice of the event on which claim is based must be given to the Plan Coordinator within 20 days after the loss for which claim is made. Late notice will be accepted only if it is furnished as soon as is reasonably possible.
On receipt of such notice, you will be given forms for filing proof of claim. If you have not been given such forms within fifteen days after the receipt of notice, you can fulfill the terms of the Plan as to proof of claim by giving written proof of. (I) the occurrence of the loss: (ii) the nature of the loss; and (iii) the extent of the loss.
Such proof must be given within the time stated in "Proof of Claim" below.
Proof of Claim: Written proof of claim must be given to the Plan Coordinator within 90 days after the date of loss for which claim is made. Late proof will be accepted only if it is furnished as soon as is reasonably possible. Itemized bills may be required as part of proof of claim.
Examinations: The Plan Coordinator at its own expense has the right to have a doctor examine any person when it deems it reasonably necessary while there is a claim pending under the plan.
Legal Actions: No one may sue for payment of claim less than sixty days after due proof of claim is furnished or more than 2 years after the date proof of claim is required by the plan.
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