A&M Dental Plan - Updated September 2015
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A&M Dental Plan Updated September 2015
INTRODUCTION
The Texas A&M University Clerical or enrollment errors do
System provides dental not obligate the plan to pay benefits.
Errors, when discovered, will be cor-
benefits to help you and your
rected according to the provisions of
family maintain good dental
the plan description and published
health. procedures of the A&M System.
D ental care is a key part of overall
health care for you and your fam-
ily. Through The Texas A&M Univer-
PRIVACY INFORMATION
Certain personal information must
be gathered by the A&M System and
sity System Dental Plan, you can en-
Delta Dental to administer your dental
sure that you and your family always
benefits. Both organizations maintain
have access to good dental care.
strict confidentiality of your records,
The A&M Dental plan emphasizes
with access limited to those who need
preventive care — to help avoid those
information to administer the plan or
painful and expensive procedures that
your claims.
can result from not getting good care
Both Delta Dental and the A&M
on a continuous basis. But recognizing
System maintain physical, electronic
that dental problems can occur even
and procedural safeguards to pro-
with regular care, the plan also covers
tect personal data from unauthorized
most other types of dental treatment.
access and unanticipated threats or
The A&M Dental plan is funded
hazards.
by The Texas A&M University Sys-
Names, mailing lists and other in-
tem, and claims are administered by
formation is not sold to or shared with
Delta Dental Insurance Company
outside organizations. Personal infor-
(Delta Dental).
mation is not disclosed except where
This booklet provides a summary
allowed or required by law or when
of your dental coverage in everyday
you give permission for information
language. Most of your questions can
to be released. These disclosures are
be answered by referring to this book-
usually made to affiliates, adminis-
let.
trators, consultants, and regulatory
This plan is governed by a plan
or governmental authorities. These
document that includes the informa-
groups are subject to the same poli-
tion in this booklet plus additional
cies regarding privacy of our informa-
administrative details.
tion as we are.
This booklet is neither a contract
of current or future employment nor
a guarantee of payment of benefits.
The A&M System reserves the right to
change or end the benefits described in
this booklet at any time for any reason.
Dental 1TABLE OF CONTENTS
PARTICIPATION 3
All full-time and some part-time employees and retirees and
their eligible dependents are eligible for A&M Dental coverage.
Coverage can begin on your first day of work.
COVERAGE COST 6
You pay the cost of dental coverage. You can pay your premiums
on a before-tax basis.
HOW DENTAL COVERAGE WORKS 7
The dental plan covers preventive, basic, major and orthodontic
care. The plan pays up to $1,500 a year in benefits, with a $1,500
lifetime maximum on orthodontic care.
COVERED DENTAL EXPENSES 10
The dental plan covers regular checkups and routine care such
as fillings, x-rays, cleanings and extractions. Other treatments
are also covered, including orthodontic care.
DENTAL EXPENSES NOT COVERED 12
Charges for cosmetic work, charges that are not medically
necessary, charges above the maximum plan allowance and
certain other items are not covered by the dental plan.
FILING CLAIMS 14
Your provider or you, must file a claim for reimbursement of
dental expenses with Delta Dental. If a claim is denied, you
may follow an appeal process.
COORDINATION OF BENEFITS 17
Your dental benefits are coordinated with other group plans
so your combined benefits are not more than 100% of the expense.
WHEN COVERAGE ENDS 18
In most cases, coverage ends on the last day of the month in
which your employment ends. You can continue your coverage
under COBRA for a limited time.
ADMINISTRATIVE AND PRIVACY INFORMATION 23
Here are some additional facts about the plan you might want to
keep handy.
2 DentalPARTICIPATION
All full-time and some part- a foster child under a legally su-
time employees and retirees pervised foster care program,
a child for whom you are the legal
and their eligible dependents
guardian or legal managing con-
are eligible for A&M Dental
servator and with whom you have
coverage. Coverage can be- a regular parent/child relationship,
gin on your first day of work. a grandchild who lives with you,
and
Y ou and your dependents are eli-
gible to participate in the dental
plan if you:
a dependent for whom you have
received a court order to provide
coverage.
are eligible to participate in the You will be asked to provide legal
Teacher Retirement System of papers to verify your relationship to
Texas (TRS) or Optional Retire- a child who is not your natural child
ment Program (ORP), and (for example, court documentation of
work at least 50% time for at least guardianship).
4½ months. Coverage for a child may continue
You and your dependents are also beyond age 25 only if the child is
eligible if you are a graduate student mentally or physically unable to earn
employee who works at least 50% a living and is dependent on you for
time for at least 4½ months, or if support. You must notify your Human
you are a postdoctoral fellow. To be Resources office of the child’s dis-
eligible for coverage as a retiree, you ability before the child’s 25th birthday.
must meet the criteria listed in the This will allow time for you to obtain
chart on the next page. and complete the necessary forms for
Eligibility for this plan is subject coverage to continue. Periodically,
to change by the A&M System or the you may be required to provide evi-
Texas Legislature. dence of the child’s continuing dis-
ability and your support.
ELIGIBLE DEPENDENTS
You may choose to cover any or all of
ENROLLING IN THE PLAN
your eligible dependents. Dependents
Coverage for you and your dependents
eligible for coverage include:
your spouse, and
can take effect either on your hire
your unmarried dependent chil- date or on your employer contribution
dren younger than 25. eligibility date (the first of the month
Children include: after your 60th day of employment) if
a natural child, you enroll before, on or within seven
an adopted child, days after your hire date. If you enroll
a stepchild who has a regular par- beyond the seventh day after your hire
ent/child relationship with you, date, but during your 60-day enroll-
Dental 3ment period, your coverage can take effect If you choose to have your dental
either on the first of the following month coverage take effect before your employer
or on your employee contribution eligibil- contribution eligibility date, you must pay
ity date. the full monthly premium yourself.
If you do not make any changes during If you are not a new employee, but
your enrollment period, you must wait un- you are enrolling in the plan during An-
til you have a Change in Status (see page nual Enrollment, your coverage will take
5) or until the next Annual Enrollment pe- effect the following September 1.
riod to enroll. Likewise, if you gain a new If you are enrolling in the plan be-
dependent, you must enroll that dependent cause of a Change in Status (see page 5),
within 60 days or wait until the next An- your coverage will take effect the first of
nual Enrollment period. the month after you enroll.
RETIREE ELIGIBILITY
If you were retired from or employed If you were hired by the A&M Sys-
in a benefits-eligible position with the tem in a benefits-eligible position after
A&M System on August 31, 2003, you August 31, 2003, or if you left A&M Sys-
are eligible for dental coverage as a re- tem employment before August 31, 2003,
tiree when: and did not meet the criteria listed at left
you are at least age 55 and have at as of August 31, 2003, you are eligible
least 5 years of service credit, or your for dental coverage as a retiree when:
age plus years of service equal at you are at least age 65 and have at
least 80, or you have at least 30 years least 10 years of service credit, or
of service, and your age plus years of service equal
you have 3 years of service with the at least 80 and you have 10 years of
A&M System, and service credit, and
the A&M System is your last state you have 10 years of service with the
employer. A&M System, and
If you left A&M System employment the A&M System is your last state
before September 1, 2003, but you met employer.
the above criteria as of August 31, 2003, If you are in TRS, you must also pro-
you qualify for retiree benefit coverage vide documentation that you are receiv-
under these criteria. ing or have applied to receive your TRS
If you are in TRS and you retire after annuity payments.
August 31, 2003, you must also provide
documentation that you are receiving or
have applied to receive your TRS annu-
ity payments.
4 DentalFORMER EMPLOYEES CHANGE IN STATUS
You are eligible for coverage as a Once you enroll in the dental plan, you
retiree if you are a former employee can change that choice only during
who meets the eligibility criteria Annual Enrollment (changes effective
listed on the previous page. September 1) or within 60 days of a
You may apply for coverage Change in Status.
within 60 days of meeting this cri-
teria or within 60 days of leaving a Changes in Status include:
TRS-eligible position with another employee’s marriage or divorce or
state employer after meeting the death of employee’s spouse,
eligibility criteria. In these cases, you birth, adoption or death of a depen-
may choose to have your coverage dent child,
become effective on the first of the change in employee’s, spouse’s or
month following the date the Human dependent child’s employment status
Resources office receives your ap- that affects benefit eligibility, such
plication or on your employer contri- as leave without pay,
bution eligibility date (the first of the child becoming ineligible for cover-
month that falls at least 60 days after age due to reaching age 25,
the Human Resources office receives changes in the employee’s, spouse’s
your application) or a dependent child’s residence that
If you do not enroll on one of would affect eligibility for coverage,
these dates, you may enroll during employee’s receipt of a qualified
a later Annual Enrollment period. medical child support order or letter
In that case, you can choose to have from the Attorney General ordering
your coverage become effective on the employee to provide (or allow-
the next September 1 or December 1. ing the employee to drop) medical
coverage for a child,
YOUR OPTIONS changes made by a spouse or de-
The Dental plan is available to active pendent child during his/her annual
and retired employees. enrollment period with another
You also have a choice of four employer,
levels of coverage: the employee, spouse or dependent
employee/retiree only, child becoming eligible or ineligible
employee/retiree and spouse, for Medicare or Medicaid, or
employee/retiree and children, or significant employer- or carrier-ini-
employee/retiree and family tiated changes in or cancellation of
(spouse and children). the employee’s, spouse’s or depen-
If you enroll your dependents, dent child’s coverage.
you must enroll them in the same Changes in coverage must be con-
plan in which you enrolled yourself. sistent with the Change in Status. For
example, if you have a baby, you may
add that child to your coverage, but you
may not drop your other children.
Dental 5COVERAGE COST
You pay the cost of dental cov-
erage. You can pay your premi-
ums on a before-tax basis.
Y ou must pay premiums for dental
coverage. If coverage for you or
your dependents begins in the middle of
a month, you must pay your share of the
premium for the entire month.
Through the Pretax Premiums Plan,
your share of any premium is automati-
cally deducted from your paycheck on a
pretax basis. This means you never pay
federal income tax or Social Security tax
on the money you pay for your dental
coverage.
When you pay premiums on a re-tax
basis, your taxable income is reduced.
This may mean that your eventual Social
Security benefit could be reduced. How-
ever, the reduction is quite small. Your
base pay, for purposes of pay increases
and benefits based on pay, is not reduced.
If you participate, your dependent’s
premiums will be deducted on a pretax
basis as well.
If you would prefer to have your
contributions paid after taxes have been
deducted, contact your Human Resources
office for the
correct form.
You may change to or from pretax
premiums only during Annual Enrollment
each year (effective September 1).
6 DentalHOW DENTAL COVERAGE
WORKS
The dental plan covers pre- major services combined in a plan
year, the plan pays no further benefits
ventive, basic, major and
for that plan year.
orthodontic care. The plan Each covered person can receive
pays up to $1,500 a year in a lifetime maximum benefit of $1,500
benefits, with a $1,500 life- for orthodontic care.
time maximum on orthodon-
tic care. ANNUAL DEDUCTIBLE
You must first meet an annual deduct-
Y our dental plan covers most
types of dental care, but at
different benefit levels. In general,
ible before you receive dental benefits,
except for preventive care.
This means you pay the first dental
here’s how the plan works: expenses (other than preventive) you
The plan pays 100% of Delta have for yourself and your covered
Dental’s allowed amount for certain dependents each year.
preventive care. You must meet a $75 If you have dependent coverage,
deductible each plan year (September the maximum annual deductible for
1–August 31) before the plan pays all family members is three times the
benefits for basic, major or orthodon- individual deductible. All expenses in-
tic care. curred by any combination of three or
Once you meet your annual de- more family members will go toward
ductible, the plan pays 80% of basic meeting the family deductible.
and 50% of major and orthodontic Preventive care expenses do not
care. When you have received $1,500 count toward the deductible, since the
in benefits for preventive, basic and allowable amount is paid at 100%.
The plan pays You pay your $75 annual deductible
100%* for Basic Major Orthodontic
preventive care. You The plan You pay The plan You The plan
pay pays 50% pays pay pays
20% 80%* 50%* 50% 50%*
Once you have received $1,500 in benefits in a plan year, Once you have
you pay all remaining dental expenses for that plan year. received $1,500
in benefits in
*Of Delta Dental’s allowed amount. your lifetime, you
pay all remain-
ing orthodontic
expenses.
Dental 7COST SHARING CHOICE OF DENTIST
You and the plan share many costs on You can choose a Delta Dental PPOSM
a percentage basis. For basic services, Dentist (PPO Dentist), a Delta Dental
after you meet your annual deduct- Premier® Dentist (Premier Dentist) or a
ible, you pay 20% and the plan pays non-Delta Dental Dentist:
80% of expenses. You and the plan Choosing a PPO Dentist gives you
each pay 50% for major and orth- the greatest reduction in your out-
odontic care, after you meet your of-pocket cost because these dentists
annual deductible. have contracted with Delta Dental to
charge less than what most dentists
PLAN LIMITS in your area charge.
The plan pays up to $1,500 per person Choosing a Premier Dentist allows
per plan year for preventive, basic and you to receive dental care at a cost
major services combined. The plan that is usually lower than a non-
also pays up to $1,500 in each per- Delta Dental Dentist’s charges but
son’s lifetime for orthodontic care. more than a PPO Dentist’s charges.
Any orthodontic benefits previ- Premier Dentists charge either their
ously received under this plan count regular fees, the Premier contracted
toward this lifetime maximum. fee or the maximum plan allowance
(see below), whichever is less.
PRE-TREATMENT ESTIMATES
If your dentist recommends treatment that will cost more than $300, you should
submit a treatment plan to Delta Dental in advance. Delta Dental will figure your
benefit under this plan before you receive treatment. This will allow you and your
dentist to know before you agree to treatment exactly how much the plan will pay
and how much you will have to pay.
Many dental problems can be treated in more than one way. The plan will pay
benefits based on the generally accepted treatment that provides adequate care
at the lowest cost. For example, veneer materials may be used for front teeth or
bicuspids. The plan will pay benefits based on the least expensive adequate veneer
material.
If the treatment your dentist proposes is not the least expensive acceptable
treatment, a pretreatment estimate will let you know that in advance. You can then
discuss with your dentist the alternative treatments and make your decision based
on your benefits allowed by the plan.
Pre-treatment estimates are valid for 60 days from the date of the pre-treat-
ment estimate, until you become ineligible for dental coverage or until the plan
ends, whichever occurs first.
8 Dental If you choose a non-Delta Den- Dentists are regularly added to or de-
tal Dentist, Delta Dental will leted from the panel, so a new dentist
pay the dentist’s charge or the may not be listed, and you should
maximum plan allowance (see always verify with Delta Dental that a
below), whichever is less. You listed dentist is
must pay any remaining charges. still in the network.
In addition, a PPO Dentist or
Premier Dentist will file claims for MAXIMUM PLAN
you. You pay only the deductible ALLOWANCE
and your coinsurance. Delta Dental The Maximum Plan Allowance
will pay the dentist directly for the (MPA) is the highest amount Delta
remaining cost up to the maximum Dental will reimburse for a covered
benefit (see Plan Limits, previous procedure. Delta Dental sets MPAs
page). each year based on actual claims sub-
Dental providers can be located mitted by providers in the same
through http://www.deltadentalins. geographic area with similar profes-
com, the A&M System dedicated sional standing. The MPA may vary
site, http://deltadentalins.com/tamus, by the type of dentist.
or your Human Resources office.
Dental 9COVERED DENTAL EXPENSES
The dental plan covers regu- full-mouth x-rays, including pano
lar checkups and routine care graph once each three years,
bitewing x-rays, up to twice each
such as fillings, x-rays, clean-
plan year,
ings and extractions. Other
space maintainers for children
treatments also are covered, younger than 14, and
including orthodontic care. sealants, limited to once per tooth
within 24-months; up to age 16 for
Y our dental plan covers most
medically necessary, reasonable
first and second molars.
and customary charges for services BASIC CARE
provided by: For in-network services, the plan pays
licensed dentists,
80% after the deductible for:
doctors operating within the scope
extractions,
of their licenses, and restorative fillings, including
licensed dental hygienists
amalgam, acrylic, or composite
operating within the scope of their fillings,
licenses and under the supervision oral surgery,
and direction of dentists or general and local anesthetic for
doctors. covered oral surgery procedures,
This section lists the expenses covered administration of nitrous oxide for
by the plan. Some limitations may use as sedation and/or analgesic
apply to specific services as noted in for children up to age 14,
this list. Expenses that are not cov- treatment of periodontal and other
ered are listed beginning on page 12. diseases of the gums and tissues
If you cannot find a service or supply supporting the teeth (except
in either section, call Delta Dental’s periodontal cleanings, which are
Customer Service department at covered as preventive care if proof
1 (800) 521-2651 to find out if the of prior root planing and scaling
expense is covered. or osseous surgery is provided),
endodontic treatment, including
PREVENTIVE CARE root canals, if the tooth is opened
For in-network services, the plan pays while the patient is covered by the
100%, with no deductible, for: plan,
oral exams, up to three each plan
injection of antibiotic drugs,
year, recementing of crowns, inlays and
prophylaxis (cleaning), including
bridgework (certain limitations
periodontal prophylaxis, up to may apply),
three each plan year, realignment of dentures, up to
topical application of fluoride for
once every two plan years, and
children younger than 15, up to emergency palliative (pain)
twice each plan year, treatment.
10 DentalMAJOR CARE ORTHODONTIC CARE
For in-network services, the plan pays The plan will pay 50% after the de-
50% after the deductible for: ductible for treatment, materials and
implants (prosthetic appliances supplies related to orthodontic treat-
placed into or on the bone of the ment. The plan will pay 50% of your
maxilla or mandible (upper or down payment, which may not exceed
lower jaw) to retain or support one third of the total cost or $700,
dental prosthesis). whichever is less, for orthodontic
inlays, onlays, gold fillings or treatment. The remaining cost will be
crowns, divided by the number of months of
initial installation of fixed bridge- expected service (generally 24
work, including inlays and crowns, months). You will be reimbursed
or replacement of existing bridge- 50% of this monthly cost each month.
work or the addition of teeth on Orthodontic benefits are limited to
existing bridgework, and $1,500 per covered person per life-
initial installation of partial or full time.
removable dentures, the replace- If you or a covered dependent
ment of an existing partial or full begins orthodontic treatment before
removable denture or the addition becoming covered under this plan, this
of teeth to a partial removable plan may pay for part of the treatment.
denture. However, initial installa- The plan will pay no benefits for the
tion and replacements or additions placement of the appliance if that step
to existing dentures or bridge- pre-dated plan coverage. However,
work will be covered only if the the plan will pay for the ongoing
work cannot be repaired and were treatment that occurs after coverage
installed at least five years before begins. In this case, Delta Dental
replacement. will make monthly payments on the
If your dental coverage ends while first payment due date after your cov-
you are in the middle of treatment erage becomes effective.
for major services, coverage may be If coverage ends before your treat-
extended for that service. If you are ment is finished, Delta Dental will
not entitled to benefits under any other make its last orthodontic payment on
dental plan and installation of a dental the first payment due date after your
appliance, crown, bridge or gold resto- coverage ends or on the last
ration is performed within 30 days of payment due date before the plan ter-
the end of your coverage, benefits for minates, whichever occurs first.
the installation will be paid if: If an interceptive appliance, such
an impression for the appliance as an expander, is placed before the
was taken before coverage ended, orthodontic work begins, benefits for
or the related charges would be con-
the tooth was prepared for the sidered part of the $1,500 maximum
crown, bridge or gold restoration orthodontic benefit.
before coverage ended.
Dental 11DENTAL EXPENSES NOT
COVERED
Charges for cosmetic work, Recementations within six months
charges that are not medical- by the same dentist/dental office,
ly necessary, charges above Recementations in excess of one
recementation by the same dentist/
the maximum plan allowance
dental office.
and certain other items are for dentures, crowns, inlays, on-
not covered by the dental lays, bridge work or other treat-
plan. ment, material or supplies pro-
vided to alter vertical dimension
W hile most dental expenses are
covered by this plan, some
dental expenses are not covered. Most
or alter occlusion,
for failure to keep a scheduled ap-
pointment with a dentist,
of these are listed below. Others that for services restoring tooth struc-
are specific to a certain service are ture lost from wear, erosion, or
listed in the section “Covered Dental abrasion, for rebuilding or main-
Expenses.” taining chewing surfaces due to
If you cannot find a specific ex- teeth out of alignment or occlu-
pense listed in this section or in the sion, or for stabilizing the teeth
list of covered expenses beginning on including equilibration and peri-
page 10, call Delta Dental’s Customer odontal splinting.
Service department at for sealants except as explained on
1 (800) 521-2651. page 10, or other materials to
prevent decay other than fluorides,
Expenses that are not covered include, for accidental injury or illness
but are not limited to: related to any employment or for
for any treatment, including which the patient is entitled to or
materials and supplies, not begun has received benefits or a settle-
and completed while the patient ment from any workers’ compen-
is covered by the plan, except as sation or occupational disease law,
explained on page 11, due to war or any act of war,
for repair and/or replacement of whether declared or undeclared,
lost, missing or stolen prosthetic for telephone consultations, re-
or orthodontic appliances, cords or x-rays necessary for Delta
for prescription drugs, although Dental to make a benefit determi-
these may be covered by your nation, that would not have been
health plan, made if you did not have cover-
for any treatment, material or sup- age,
plies that are for orthodontic treat- that you are not legally obligated
ment, except as explained on page to pay, except charges from a tax-
11.
12 Dentalsupported institution of the State • surgical reconstruction or cor-
of Texas for care of mental illness rection of a defect resulting
or retardation and charges for ser- from surgery while you were
vices or materials provided under covered by the plan,
the Texas Medical Assistance Act for extraoral grafts (grafting of
of 1967, tissues from outside the mouth to
for services or supplies furnished oral tissues),
by an agency of the U.S. or a for- for scholastic education or voca-
eign government, unless exclud- tional training,
ing the charges is illegal, for care, treatment, services or
supplies that are experimental or
for services while you are not
investigative in terms of gener-
under the direct care of a dentist, ally accepted medical and dental
for treatment by a dentist that is standards,
not within the scope of his/her for travel, even if recommended
license, by a dentist,
for services of a person who is a for adjustment of a denture or
member of your or your spouse’s bridgework within six months af-
immediate family or who lives ter installation by the same dentist
with you, who installed it,
for personalized complete or for instruction for oral care, such
partial dentures, overdentures and as hygiene or diet,
their related procedures, for myofunctional therapy or cor-
for treatment that is not medically rection of harmful habits, such
as night guards or appliances to
necessary, except those preven-
prevent teeth grinding,
tive benefits described on page
for charges made by a dentist for
10, completing dental forms,
for services and materials in ex- for more than one consultation in a
cess of the maximum plan allow- plan year,
ance as described on page 9, for for the administration or cost of
which benefits are not provided drugs and/or gases used for seda-
under this plan, tion or as an analgesic for adults
for expenses charged by a hospi- and children over age 14, unless
tal or surgical or treatment facility medically necessary,
and any additional fees charged and charges related to temporo-
by the dentist for treatment in any mandibular joint problems (how-
such facility, ever, these may be covered under
your health plan).
for cosmetic surgery or treatment,
unless due to:
• an accident that occurred
while you were covered by
the plan,
• a birth defect if your child is
continuously covered by this
plan from date of birth, or
Dental 13FILING CLAIMS
You must file a claim for ing, payment of your benefits may be
reimbursement of dental delayed.
expenses with Delta Dental. For orthodontic claims, you should
first submit the bill for your down
If a claim is denied, you may
payment with a claim form. Then you
follow an appeal process. must submit claims for each of your
T
monthly bills.
o file a claim for dental benefits,
You need to file all claims for a
you must complete a claim form
plan year soon after the end of that
(pictured on the following page) and
plan year (August 31). All claims must
mail it with a copy of your bill to the
be received by January 31 of the next
address shown on the claim form.
plan year. The plan is not obligated to
Claim forms are available from
pay claims received after that date.
your Human Resources Office or at
Delta Dental’s web site:
www.deltadentalins.com.
OVERPAYMENTS
If Delta Dental overpays a claim for
PPO Dentists and Premier Dentists
any reason, the plan has the right to re-
will be paid directly by Delta Dental
cover the overpaid amount from you.
for services provided under the plan.
You may request, in writing, when
filing proof of loss that payment
HOW TO APPEAL A CLAIM
If your claim for benefits is denied
be made directly to a non-Delta Den-
in whole or in part, Delta Dental will
tal Dentist. All benefits not paid to
notify you in writing within 90 days of
the dentist will be paid to you or your
receipt of your claim.
estate, except if the person receiving
The written notice will give spe-
payment is a minor or otherwise not
cific reasons for the denial and refer-
competent to give a valid release. In
ence the specific plan provisions on
such event, benefits may be paid to
which the denial is based. It will also
that person’s parent, guardian or other
describe any additional material you
person supporting him or her.
must submit and explain the plan’s
Be sure to keep a copy of your
claim review procedures.
claim for your records. You must send
In special circumstances, a re-
the original claim form and bill to:
sponse to your claim may take more
than 90 days. If an extension is need-
Delta Dental Insurance Company
ed, you will receive written notice
Claims Department
before the end of the 90-day period.
P.O. Box #1809
In no event will the extension be more
Alpharetta, Georgia 30023
than 90 days.
Within 60 days of receiving writ-
Be sure to fill out the claim form
ten notice of a claim denial, you or
completely. If information is miss-
your authorized representative may
14 Dentalsubmit a written request for recon- after receipt of your request. The deci-
sideration to Delta Dental. Be sure sion on the review will be in writing
to state why you believe the claim and will include the specific reasons
should not have been denied and sub- for the decision as well as specific ref-
mit any data, questions or comments erences to the appropriate plan provi-
you think are appropriate. You may sions on which the decision is based.
also review any pertinent plan docu-
ments. Your appeal will be reviewed A&M SYSTEM REVIEW
by the claims administrator. If you are not satisfied with the deci-
A decision on the appeal will sion reached by the claims review
be made by Delta Dental within 60 process, you may request a review by
days after receipt of your request for the A&M System Review Panel with-
review unless special circumstances in 30 days of your receipt of the final
require additional time. A decision written decision from Delta Dental. To
will be made no more than 120 days request a review, you must send writ-
Delta Dental Insurance Company
STAPLE X-RAYS FOR ALL MAJOR SERVICES TO TOP LEFT CORNER P.O. Box 1809
OF FORMS. X-RAYS MUST BE LABELED WITH PATIENT NAME, Alpharetta, GA 30023-1809
DENTIST NAME AND ADDRESS. www.deltadentalins.com
1. PATIENT NAME 2. RELATIONSHIP TO PATIENT 3. SEX 4. PATIENT BIRTHDATE 5. IF FULL TIME STUDENT
SELF SPOUSE CHILD OTHER M F MO. DAY YEAR SCHOOL CITY
6. PRIMARY ENROLLEE FIRST MIDDLE LAST 7. PRIMARY ENROLLEE 7A. PRIMARY ENR. BIRTHDATE 9. NAME OF GROUP DENTAL PROGRAM
EMPLOYEE/ ID NUMBER MO. DAY YEAR
PLEASE MAKE SURE EMPLOYEE’S MAILING ADDRESS IS LEGIBILE, CURRENT & COMPLETE
NAME
8. ENROLLEE 7B. SPOUSE BIRTHDATE 10. EMPLOYER (COMPANY) NAME AND ADDRESS
MAILING MO. DAY YEAR
ADDRESS
CITY, STATE, ZIP
11. EMPLOYEE GROUP NUMBER 12. LOCATION (LOCAL) 13. ARE OTHER FAMILY MEMBERS EMPLOYED? 14. NAME AND ADDRESS OF EMPLOYER, ITEM 13
ENROLLEE NAME ENROLLEE ID NUMBER
15. IS PATIENT COVERED BY DENTAL PLAN NAME UNION LOCAL GROUP NO. NAME AND ADDRESS OF CARRIER
ANOTHER DENTAL PLAN?
16. DENTIST NAME 24. IS TREATMENT RESULT NO YES IF YES, ENTER BRIEF DESCRIPTION AND DATES
OF OCCUPATIONAL
ILLNESS OR INJURY?
17. MAILING 25. IS TREATMENT RESULT
ADDRESS OF AUTO ACCIDENT?
26. OTHER ACCIDENT?
CITY, STATE, ZIP IS THIS ADDRESS NEW? 27. ARE ANY SERVICES
COVERED BY
YES � NO � ANOTHER PLAN?
18. DENTIST SOC. SEC. NO. OR T.I.N. 19. DENTIST LICENSE NO. 20. DENTIST PHONE NO. 28. IF PROSTHESIS, IS THIS 29. DATE OF PRIOR
INITIAL PLACEMENT? PLACEMENT
IF NO, ENTER REASON
FOR REPLACEMENT.
21. FIRST VISIT DATE 22. PLACE OF TREATMENT 23. RADIOGRAPHS OR HOW 30. IS TREATMENT FOR NO YES IF SERVICES DATE APPLIANCES PLACED MOS. TREATMENT
CURRENT SERIES OFFICE HOSP ECF OTHER MODEL ENCLOSED? MANY? ORTHODONTICS? ALREADY REMAINING
COMMENCED
NO � YES � ENTER
31. EXAMINATION AND TREATMENT RECORD - LIST IN ORDER FROM TOOTH NO. 1 THROUGH TOOTH NO. 32 USING CHARTING SYSTEM SHOWN.
TOOTH DATE SERVICE
DESCRIPTION OF SERVICE PROCEDURE
# OR SURFACES (INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED, ETC.) COMPLETED NUMBER FEE
LETTER
MO. DAY YEAR
32. REMARKS FOR UNUSUAL SERVICES
I ACCEPT THIS ATTENDING DENTIST’S STATEMENT AND AUTHORIZE RELEASE OF INFORMATION I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE ABOVE NAMED
RELATING HERETO. I CERTIFY THE TRUTH OF ALL PERSONAL INFORMATION CONTAINED ABOVE. DENTIST OF THE BENEFITS OTHERWISE PAYABLE TO ME. TOTAL FEE
I AGREE TO BE RESPONSIBLE FOR PAYMENT FOR SERVICES PROVIDED DURING ANY INELIGIBLE CHARGED
PERIOD.
PATIENT
PAYS
PATIENT (PARENT OR
ENROLLEE) SIGNATURE X X
ENROLLEE SIGNATURE DATE PLAN
PAYS
NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
AMOUNT APPLIED
PREDETERMINATION OF COST TREATMENT COMPLETED - PAYMENT REQUESTED TO DEDUCTIBLE
THE TREATMENT LISTED IS NECESSARY IN MY PROFESSIONAL JUDGMENT AND I THE TREATMENT LISTED WAS COMPLETED ON DATES INDICATED AND WAS
REQUEST PREDETERMINATION OF BENEFITS. NECESSARY IN MY PROFESSIONAL JUDGMENT.
DENTIST DENTIST
SIGNATURE DATE SIGNATURE DATE
ATTENDING DENTIST’S STATEMENT
FORM 3105 (REV. 6-06)
Dental 15ten notification of your desire to have Within 30 days of the meeting,
your claim reviewed, with a copy of the panel will make a decision on the
Delta Dental’s decision, to: case, unless special circumstances
require additional time. You may ad-
Employee Benefits Manager dress the panel and submit relevant
The Texas A&M University System information and expert opinions and/
Moore/Connally Building or witnesses. You must submit at least
301 Tarrow, 5th Floor 10 copies of all documentation on
College Station, TX 77840 your claim problem to the Employee
Mail Stop: 1117 TAMU Benefits Manager at least 72 hours
before the meeting with the panel.
If you or any of your witnesses or You also must inform the Em-
representatives wish to meet with the ployee Benefits Manager at least 72
Review Panel from outside College hours in advance of the meeting of
Station using the Trans-Texas Video any witnesses or representatives you
Network, your notification letter must will have at the meeting. You are
state that preference. responsible for any expenses arising
Within five working days of from use of witnesses or representa-
receiving your letter, the Employee tives.
Benefits Manager will mail you ac- The Employee Benefits Manager
knowledgment of your request. This will notify you and Delta Dental of
mailing will include release forms that the panel’s decision. This will be the
you must sign to authorize the release final decision on your case, and the
of relevant information about the panel will not review it again.
problem to members of the Review If the review panel’s decision
Panel and to release panel members would require the plan to violate state
from any and all liability arising from or federal law or A&M System policy
the panel’s conclusions. or regulation, the plan administra-
You must return the release forms tor, after consulting with the General
to the Employee Benefits Manager Counsel, may prohibit implementa-
within 30 days of receiving the forms. tion of the panel’s decision.
Within 10 working days of receiv- You may cancel a review of your
ing the release forms, the Employee case at any time by written request to
Benefits Manager will contact the the Employee Benefits Manager.
Review Panel members and set a
review date. This group will meet to
review the case within 30 days of the
Employee Benefits Manager’s notifi-
cation to the panel.
16 DentalCOORDINATION OF BENEFITS
Your dental benefits are COB provisions, the chart below
coordinated with other group shows which plan is designated as pri-
plans so your combined mary or secondary under COB rules.
If the parents of a covered depen-
benefits are not more than
dent child are divorced, the plan of the
100% of the expense. parent who has financial responsibility
for that child’s dental care expenses
I n many families, especially if both
husband and wife work, family
members may be covered by more
under a court decree is primary. If no
decree establishes financial respon-
sibility, the plan of the parent with
than one dental plan. Each plan pays
custody is primary. If there is no
benefits, but the plans coordinate
financial decree and the parent with
their payments so that the total pay-
custody remarries, that parent’s plan is
ments are not more than 100% of the
primary, the stepparent’s plan is sec-
allowable expenses. Coordination of
ondary and the other natural parent’s
benefits (COB) rules determine the
plan pays third.
sequence of payments.
If you or your spouse are covered
One plan has primary responsibil-
under one employer’s plan as a retired
ity and pays first; the other plan has
or laid-off employee and under an
secondary responsibility and pays
other plan as an active employee, the
benefits for any additional covered
plan that covers you as an active
expenses. When A&M Dental is the
employee pays first.
secondary payor, the A&M Dental
If none of these rules apply, the
benefit is based on the total billed
plan that has covered the person for
charge, subject to the maximum plan
the longest period will pay first.
allowance limits (see page 9).
These rules apply to any other
A plan that has no coordination of
group coverage or government pro-
benefits provision is always primary.
gram, except Medicaid. Any personal
If a husband and wife both cover the
dental care policies you may have are
family under plans through their em-
not affected by the COB rules.
ployers and both plans have
CLAIMANT PRIMARY PLAN SECONDARY PLAN
Wife Wife’s Husband’s
Husband Husband’s Wife’s
Child Parent’s whose birthday is Other parent’s
earliest in the calendar year*
* This assumes both plans have this rule. If not, the other plan’s rules determine which plan is
primary.
Dental 17WHEN COVERAGE ENDS
In most cases, coverage the last day of the month in which
ends on the last day of the you elect to drop dependent cov-
month in which your em- erage due to a Change in Status,
or
ployment ends. You can
the day the plan stops offering
continue your coverage dependent coverage.
under COBRA for a limited
time. A divorce is considered official
when the trial court announces its
Y
our coverage will end on the
earliest of the following dates:
the last day of the month in
decision in open court or by written
memorandum filed with the clerk.
which your employment ends WHEN COVERAGE IS
or you become ineligible for EXTENDED
coverage. In some cases, your coverage can
the last day of the last month for be extended due to changes in your
which you pay your full pre- A&M System employment.
mium,
the last day of the plan year if Approved Leave of Absence: If you
you elect during Annual Enroll- take a paid leave, including a paid
ment not to continue coverage, military leave, your coverage can
the last day of the month in continue and your premiums
which you elect to terminate will continue to be deducted from
coverage due to a Change in your pay. If you pay part or all of
Status, or your premiums with the employer
the day this plan ends. contribution, you will continue to
receive the contribution while on
Coverage for your dependents leave during any month in which you
ends on the earliest of the following receive some pay from the state.
dates: If your leave is unpaid, includ-
the day your coverage ends, ing an unpaid military leave, you
the last day of the month in may make arrangements to pay your
which the dependent stops premiums.
meeting the eligibility require- Should you drop coverage while
ments, on an unpaid leave, your coverage
the last day of the month for will automatically be reinstated when
which you pay your full premi- you return to work regardless of the
um for dependent dental cover- plan year. You have 60 days after
age, your return to change your election.
the last day of the plan year if
you elect during Annual Enroll- Family or Medical Leave: If you
ment not to continue dependent take an unpaid leave of absence, any
dental coverage, employer contribution toward your
18 Dentaldental coverage normally will end. bution, if applicable) for the first 60
However, if you take a family or months of your disability.
medical leave under the Family and If you had worked for the A&M
Medical Leave Act, the employer System less than 18 months, you
contribution toward your coverage may continue coverage for up to a
will continue for up to 12 weeks. total of 18 months if you elect CO-
If you do not pay your share, if BRA coverage for any months
any, of the premiums for coverage in excess of the number of months
while on a family or medical leave, you worked. If you are approved for
your dependents’ coverage will be Social Security disability benefits
dropped and, if the employer contri- within 60 days of the date your cov-
bution does not fully cover premiums erage would otherwise end, you may
for your coverage, your coverage continue coverage for an additional
will be dropped. 11 months. COBRA is explained
Your coverage will be automati- later in this section.
cally reinstated when you return, and If you end your employment
you have 60 days after your return to when you become disabled without
change your election. taking advantage of this extended
coverage, you become immediately
Total Disability: If you become dis- eligible for COBRA continuation
abled, your coverage will continue, of coverage.
if you continue to pay the premiums,
while you are on sick leave or vaca- Retirement: You may continue den-
tion. You also may pay to continue tal coverage if you meet the criteria
coverage while you are on leave for retirement outlined on page 4.
without pay or workers’ compensa-
tion leave. Survivors: If you die while actively
If you qualify for disability employed, your spouse may continue
retirement under TRS, whether or coverage until he/she remarries and
not you are a member of TRS, your your children may continue coverage
coverage can continue throughout until they no longer meet the depen-
your disability, if you continue to dent eligibility requirements if:
pay the premiums. If you become you were younger than 55,
disabled as defined by TRS and have your age and service combined
less than 10 years of service, you were less than 80 years,
may continue coverage (and receive you had less than 30 years of
the state contribution, if applicable) service,
for the same number of months as your dependents were covered at
you had worked for the A&M Sys- the time of your death, and
tem. For example, if you had worked you had been covered by the
for the A&M System for 60 months plan for at least five consecutive
and then became disabled, you could years.
continue your coverage (and con- If your dependents were cov-
tinue to receive the employer contri- ered at the time of your death, your
spouse can continue coverage indefi-
Dental 19nitely, including after remarriage, and Part-Time Employee: If your budget-
your children can continue coverage ed employment is reduced to less than
until they no longer meet the depen- 50% time after you have been covered
dent requirements if: by this plan for at least 4½ continuous
you were at least 55 years old and months, you can continue your dental
had at least five years of service, coverage.
your age and service combined
totals at least 80 years, COBRA COVERAGE
you were any age and had at least CONTINUATION
30 years of service, or In some cases, you, your spouse
you were a retiree of the A&M (including a former spouse) and your
System. children have the option to extend
In either case, your dependents coverage beyond the time it would
must pay to continue coverage. normally end by paying the full cost
If your dependents do not qualify of coverage. The chart below de-
under either of these provisions to scribes these cases.
continue coverage, they may qualify If, in anticipation of a divorce,
for COBRA coverage as explained you drop your spouse’s dental cover-
later in this section. age during Annual Enrollment or due
COBRA QUALIFYING EVENTS AND CONTINUATION PERIODS
IF... IF...
Your employment ends for any reason You die, or
(other than gross misconduct),or You divorce or legally separate...
You go on leave without pay, or
Your hours are reduced so that you are
no longer eligible...
THEN... THEN...
Coverage for you and/or your covered Coverage for your covered fam-
family members can be extended for up ily members can be extended for
to 18 months. up to 36 months.
IF... IF...
Your covered child no longer qualifies You elect extended coverage
for coverage... due to employment termination,
leave without pay or reduction in
hours and you or a covered fam-
ily member qualifies for Social
Security disability benefits within
60 days of the date coverage
ends...
THEN... THEN...
Coverage for the child can be extended Coverage for the disabled person
for up to 36 months. and all covered family members
can be extended for up to 29
months.
20 Dentalto a change in status, under certain You must notify the A&M Sys-
circumstances your spouse will be of- tem when you or family members
fered COBRA continuation coverage experience certain events that would
from the date of the divorce if you cause coverage to end. In other cases,
or your ex-spouse notifies your Hu- you will not have to provide notifica-
man Resources office of the divorce. tion. See the chart on the previous
Coverage will not be available for page for notification, election and
the time between the date you first payment deadlines. Failure to meet
dropped your spouse’s coverage and these deadlines will cause you or
the divorce date. your dependents to lose your right to
continue dental coverage.
COBRA TIMELINE
IF... IF...
You divorce, or You leave employment,
Your child becomes ineligible for Your hours are reduced,
coverage You go on leave without pay,
or
You die
THEN... THEN...
You and/or your dependents have 60 The A&M System has 14 days
days after the event to notify Human after the event (or notification
Resources of the event of your death) to send you and/
or your dependents a COBRA
The A&M System has 14 days after enrollment form
your notification to send you and/or
your dependents a COBRA enrollment You and/or your dependents have
form 60 days after the event or date
the COBRA enrollment form was
You and/or your dependents have 60 sent, whichever is later, to elect
days after the event or date the COBRA COBRA coverage and return our
enrollment form was sent, whichever enrollment form
is later, to elect COBRA coverage and
return your enrollment form You and/or your dependents have
45 days after making your elec-
You and/or your dependents have 45 tion to pay back premiums
days after making your election to pay
back premiums
If you or your dependent becomes eligible for Social Security disability ben-
efits within 60 days of the date your coverage ended, you or your dependent
must notify your Human Resources office within 60 days of receiving notice
from the Social Security Administration. If you and/or your dependents miss
any of these deadlines, you and/or your dependents forfeit your rights to con-
tinue coverage.
Dental 21After you notify the A&M ,I\RXUFKLOGVWRSVTXDOLI\LQJIRUcoverage
System of an event or after an event (for example, due to marriage or age)
not requiring notification, the A&M during the initial extension period, that
System will send enrollment forms child may extend coverage for an
within 14 days directly to the person additional 18 months for a total
eligible for extended coverage. extension of 36 months.
Included with the enrollment forms To be eligible for the additional
will be information about rights to extended coverage, your covered
extended coverage and the costs of family members must notify the
this coverage. A&M System within 60 days of the
You and/or your dependents then occurrence of one of these events.
must make your election and pay When a person on 18 months of
premiums within the times outlined COBRA coverage becomes disabled
in the chart on page 21. There after, within the first 60 days of COBRA
premiums for continuing coverage, that person and other
coverage must be paid by the date covered family members may extend
specified by the A&M System. COBRA coverage for an additional
To continue coverage, you and/or 11 months. To do so, the disabled
your covered family members must person or a family member must
pay the full premium plus an ad- notify the appropriate institution or
ditional 2% to cover administrative agency Human Resources office of
costs. The cost of coverage will be the disabled person’s eligibility for
approximately 50% higher during Social Security disability benefits.
the final 11 months of COBRA This notification must be made
coverage due to a Social Security- within 60 days of the disabled person
eligible disability if the disabled per- receiving the determination
son alone or the disabled person and from the Social Security Administra-
other family members elect to extend tion and before the end of the initial
coverage during that period. The cost 18-month COBRA period.
will remain 2% higher if the disabled Coverage stops before the end of
person does not, but family members the extension period if:
do, extend coverage. the required premium is not paid,
If you and covered family mem- you or a family member becomes
bers elect extended coverage due covered under another group
to your termination of employment dental plan, unless that plan has a
or reduction in hours, your covered pre-existing condition provision
family members may elect an ad- that limits your benefits, or
ditional extension period of up to the A&M System no longer of
18 months (for an overall total of 36 fers dental coverage to its em-
months) if during the initial exten- ployees.
sion period:
you die, or
you divorce.
22 DentalADMINISTRATIVE AND PRIVACY
INFORMATION
Here are some additional CLAIMS ADMINISTRATOR
facts about the plan you The Texas A&M University System
might want to keep handy. is liable for all benefits under this
plan. However, Delta Dental, in
PLAN NAME accordance with an administrative
The official name of this plan is services agreement between Delta
The Texas A&M University System Dental and The Texas A&M Univer-
Group Dental Program. This book- sity System, supervises and adminis-
let also describes The Texas A&M ters the payment of claims.
University System Pre-Tax Premium
Plan. Claims should be sent to:
PLAN SPONSOR Delta Dental Insurance Company
Director of Risk Management and Claims Department
Benefits Administration P.O. Box #1809
The Texas A&M University System Alpharetta, Georgia 30023
Moore/Connally Building
301 Tarrow Dr., 5th Floor The Pre-Tax Premium Plan
College Station, TX 77840 claims administrator is the Plan Ad-
Mail Stop: 1117 TAMU ministrator.
1 (979) 458-6330 The A&M Dental and Pre-Tax
Premium Plan legal documents
PLAN ADMINISTRATOR govern all plan benefits. You may
The plan administrator is the Direc- examine a copy of the documents
tor of Risk Management and Ben- or obtain a copy for a copying fee by
efits Administration. Contact at the contacting the Plan Sponsor.
address shown for the Plan Sponsor.
PLAN FUNDING
TYPE OF PLAN The A&M Dental and Pre-Tax Pre-
The A&M Dental plan is a group mium Plan are self-funded primarily
plan providing dental benefits. The through employee contributions.
Pretax Premiums Plan is a flexible This means the money you put into
benefit plan under section 125 of the the plans is the same money that is
IRS tax code. used to pay benefits.
PLAN YEAR
Plan records are kept on a plan-year
basis. The plan year begins each
September 1 and runs through the
next August 31.
Dental 23EMPLOYEE IDENTIFICA- information is not disclosed except
TION NUMBER where allowed or required by law or
74-2648747 unless you give permission for infor-
mation to be released. These disclo-
GROUP NUMBER sures are usually made to affiliates,
4170-0001 administrators, consultants, and
regulatory or governmental authori-
AGENT FOR SERVICE OF ties. These groups are subject to the
LEGAL PROCESS same policies, as we are, regarding
Plan Administrator privacy of our information.
The A&M System may use and
PRIVACY INFORMATION disclose your protected health infor-
The A&M System and Delta Dental mation (PHI) without your written
must gather certain personal infor- authorization or without giving you
mation to administer your health the opportunity to agree or disagree
benefits. Both organitions maintain when your PHI is required:
strict confidentiality of your records, for treatment
with access limited to those who for payment
need information to administer the for health care operations
plan or your claims. by law or, under certain circum-
Delta Dental gathers informa- stances, by law enforcement
tion about you from your applica- because of public health activi-
tion, claims and other forms. They ties
also have personal information that because of lawsuits and other
comes in from your claims, your legal proceedings
health care providers and other for organ and tissue donation
sources used in managing your to avert a serious threat to health
health care administration. The or safety (under certain circum-
A&M System will not use the dis- stances)
closed information to make em- because of health oversight ac-
ployment-related decisions or take tivities
employment-related actions. for worker’s compensation
Both Delta Dental and the A&M because of specialized govern-
System have strict policies and pro- ment functions (under certain
cedures to protect the confidentiality circumstances)
of personal information. in cases of abuse, neglect or
They maintain physical, electronic domestic violence
and procedural safeguards to protect by coroners, medical examiners
personal data from unauthorized or funeral directors
access and unanticipated threats or The A&M System can also
hazards. use and disclose PHI without your
Names, mailing lists and other written authorization when dealing
information are not sold to or shared with individuals involved in your
with outside organizations. Personal care or payment for your care. How-
24 Dentalever, you will have an opportunity to FUTURE OF THE PLAN
agree or disagree. If you do not While The Texas A&M University
object, the A&M System can use and System intends to continue these
disclose your PHI for this reason. plans indefinitely, it may change,
Details regarding the above suspend or end the plans at any time
situations are found in The Texas for any reason.
A&M University System’s Notice of
Privacy Practices. For an additional
copy of the notice, please contact
your benefits office or visit our
website at assets.system.tamus.edu/
benefits/pdf/hipaaprivacy.pdf.
If you have questions about the
Delta Dental privacy policy, please
write to:
Delta Dental Insurance Company
Regulatory Department
Attn: Privacy Officer
1130 Sanctuary Parkway
Suite 600
Alpharetta, GA 30009
If you feel your privacy rights
have been violated, you may file a
complaint with the A&M System
by contacting the Privacy Official
at 1 (979) 458-6330. You may also
contact the Secretary of the United
States Department of Health and Hu-
man Services at 200 Independence
Avenue, S.W., Washington, D.C.
20201 to file a complaint.
Dental 25System Benefits Administration Moore/Connally Building The Texas A&M University System 301 Tarrow Dr., 5th Floor College Station, TX 77840
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