UNITE HERE HEALTH. Summary Plan Description Long Beach/Orange County Plan Plan 278. August 2012

Transcripción

1 UNITE HERE HEALTH Summary Plan Description Long Beach/Orange County Plan Plan 278 August 2012 This Summary Plan Description supercedes and replaces all materials previously issued.

2 The Plan Administrator and the agent for service of legal process is the Chief Executive Officer (CEO) of UNITE HERE HEALTH. Service of legal process may also be made on any Plan Trustee. The CEO s address and phone number are: UNITE HERE HEALTH Chief Executive Officer P. O. Box 6020 Aurora, IL (630)

3 INTRODUCTION UNITE HERE HEALTH (the Fund) was created to provide benefits for you and your covered dependents. UNITE HERE HEALTH serves participants working for employers in the hospitality industry and is governed by a Board of Trustees composed of an equal number of union and employer trustees. Each employer contributes to UNITE HERE HEALTH according to a specific contract, called a Collective Bargaining Agreement, between the employer and the union. Your Plan, Plan 278, has been adopted by the Trustees for the payment of Medical and other health and welfare benefits from UNITE HERE HEALTH. This booklet is your Summary Plan Description (SPD). It is a summary of the Plan s rules and regulations and describes: How you become eligible; When your dependents are covered; What benefits you have; Limitations and exclusions; How to file claims; and How to appeal denied claims. If information contained in the SPD is inconsistent with those rules and regulations, the rules and regulations will govern. If information contained in the SPD is inconsistent with any insurance contract governing benefits, those insurance contracts will govern. No contributing employer, employer association, labor organization, or any individual employed by one of these organizations has the authority to answer questions or interpret any provisions of this Summary Plan Description on behalf of UNITE HERE HEALTH. 3

4 ABOUT PLAN FINANCES Who Pays for Your Benefits? Employers participating in the Plan are required to make contributions for their employees. These contributions are controlled by the terms of the Collective Bargaining Agreements negotiated by your local union. Depending on the plan of benefits you select and your Collective Bargaining Agreement, you may also be required to contribute towards the cost of Employee Coverage. The Plan is supported by employer contributions and any required contributions you make. What Benefits Are Provided Through Insurance Companies? The Plan insures both medical HMO benefit options, underwritten by Kaiser Permanente (Kaiser) and Health Net Medical Group (Health Net). The Dental Benefit options offered under Coast Dental Group, Dental Health Services/ Universal Care, and United Concordia Dental Plan are fully insured. Vision Coverage is also fully insured through a contract with UnitedHealthcare. The Plan provides the Alternate Dental Benefit as a self-funded benefit. Self-funded means that this benefit is not funded by insurance contracts. Benefits and associated administrative expenses are paid directly from UNITE HERE HEALTH. The Plan also insures Life Insurance and Accidental Death and Dismemberment Benefits. These benefits are funded and guaranteed under group contracts underwritten by Dearborn National. 4

5 IMPORTANT PHONE NUMBERS Kaiser Permanente HMO Option Only For Benefit Questions and to Find a Kaiser Permanente Doctor or Hospital After-Hours Kaiser Permanente Advice Nurse During regular business hours, contact your local Kaiser Permanente center Health Net HMO Option Only For Benefit Questions and to Find a Health Net Doctor or Hospital (800) (888) (800) Decision Power (Nurse Line) (800) Coast Plan Group Dental Option Only For benefit questions and to find a Coast Plan dentist Dental Health Services/Universal Care Option Only For benefit questions and to find a DHS dentist United Concordia Dental Option Only For benefit questions and to find a United Concordia dentist Alternate Dental Benefit For benefit questions Vision Care For benefit questions and to find a UnitedHealthcare Vision provider (714) (800) (562) (866) (855) (800) (800) (provider finder) To request enrollment or election forms, report changes in your employment or family status, inquire about claims, self-payments or request additional information, contact the Garden Grove UNITE HERE HEALTH office: Garden Grove Boulevard, Suite 200 Garden Grove, California (855) Visit our website at Set up an account on the UNITE HERE HEALTH website to check eligibility, update address information, add dependent information, and make COBRA payments online. 5

6 TABLE OF CONTENTS This Table of Contents is designed to help you find specific benefit information easily and quickly. Look for the question that best describes what you want to know. Where Does the Money to Pay Benefits Come From? About Plan Finances Who Pays for Your Benefits? What Benefits Are Provided Through Insurance Companies? What Health and Welfare Benefits Does the Plan Provide? Summary of Benefits Medical HMO Summary of Benefits Dental Options Who s Covered by the Plan? Who s Eligible Employees Dependents Who Your Dependents Are Enrollment Requirements Choice of Coverage Options Employees Dependents Dependent Documentation How Do I Use Medical HMO Coverage? Medical Benefits Options How Do I Use a Medical HMO? How the Medical HMO Contract Affects Your Benefits What Dental Services Does the Plan Cover? Dental Benefits Options Alternate Dental Benefit What the Plan Pays What You Pay Pre-determination of Benefits Alternate Course of Treatment Medically Necessary Care and Treatment What s Covered What s Not Covered Dental Benefits After Eligibility Ends Schedule of Benefits Under the Alternate Dental Benefit

7 TABLE OF CONTENTS Does the Plan Provide Benefits for Eye Exams and Glasses? Vision Care Benefits What s Covered What the Plan Pays What You Pay What s Not Covered What If I m Also Covered Under Another Dental Plan? Coordination of Benefits for the Alternate Dental Benefit Which Plan Pays First Order of Payment COB and Precertification Special Rules for Medicare Husband and Wife, or Domestic Partner, Employees Under This Plan When Must Plan Payments Be Returned? Subrogation The Plan s Right to Recover Payments When Injury Is Caused by Someone Else Statement of Facts and Repayment Agreement What If I Die? Life and Accidental Death & Dismemberment Insurance Benefit Life Insurance Benefit Amount Naming a Beneficiary Continuation If You Become Totally Disabled Converting to Individual Life Insurance Coverage Filing a Claim Accidental Death & Dismemberment Insurance AD&D Exclusions Naming a Beneficiary Filing a Claim Additional Insurance Benefits and Services Accidental Death & Dismemberment Insurance Benefits Life Insurance Benefits How Do I Become Eligible For and Then Continue Coverage? Eligibility for Coverage When Your Coverage Begins When Dependent Coverage Begins Continuing Eligibility Self-payments Self-payments During a Work Place Closing

8 TABLE OF CONTENTS Self-payments During a Strike Vacation Hours Enrollment Periods Open Enrollment Periods Employee Special Enrollment Periods Dependent Special Enrollment Periods Retiree Eligibility When Does Coverage End? Termination of Coverage When Employee Coverage Ends When Dependent Coverage Ends Certificate of Creditable Coverage When Your Employer s Collective Bargaining Agreement Expires The Effect of Severely Delinquent Employer Contributions Limited Retroactive Terminations of Coverage Allowed Remedies for Fraud What If I Lose Coverage and Then Return to Work? Re-establishing Eligibility Portability Family and Medical Leave Act The Effect of Uniformed Service How Can Coverage Be Continued? COBRA Continuation Coverage Who Can Elect COBRA Coverage? What Is a Qualifying Event? What Coverage Can Be Continued? How Long Can Coverage Be Continued? Termination of COBRA Coverage Notifying UNITE HERE HEALTH When Qualifying Events Occur Election and Payment Deadlines How Do I File a Claim and What Do I Do If It s Denied? General Claim Provisions Filing a Benefit Claim Deadlines for Filing a Benefit Claim Individuals Who May File a Benefit Claim Who Is an Authorized Representative? Payment of Claims Concurrent Care Decisions Life and Accidental Death & Dismemberment Insurance Benefit Claims Health Care Claims Not Involving Concurrent Care Decisions

9 TABLE OF CONTENTS If a Benefit Claim Is Denied Appealing the Denial of a Claim Appeals to UNITE HERE HEALTH Involving Urgent Care Claims Appeals Under the Sole Authority of the Plan Administrator Review of Appeals Notice of the Decision on Your Appeal Independent External Review Procedures for the Alternate Dental Benefit What Else Do I Need to Know? Other Important Information Interpretation of Plan Provisions Medical HMO Benefits Dental Benefits through a Dental HMO Vision Benefits Independent Review Organization All Other Authority Rests with the Board of Trustees Amendment or Termination of the Plan Providers Workers Compensation Type of Plan Employer and Employee Organizations Plan Administrator Employer Identification Number Plan Number Plan Year Your Rights Under ERISA Receive Information About Your Plan and Benefits Continue Group Health Plan Coverage Creditable Coverage Prudent Actions by Plan Fiduciaries Enforce Your Rights Assistance With Your Questions Board of Trustees Provider Organization Phone Numbers and Addresses

10 SUMMARY OF BENEFITS MEDICAL HMO The following is a summary of the benefits payable under each medical HMO option. See the Health Net or Kaiser Benefit Summary for details about the coverage paid under each HMO. Benefits payable are governed by the contract between UNITE HERE HEALTH and the medical HMO. If there are any conflicts between this summary and the contract with the HMO, the terms of the contract will govern. Description of Services Health Net HMO Kaiser Permanente HMO Calendar Year Deductible None None Calendar Year Out-of-Pocket Maximum $1,500 per person $4,500 per family (3 or more members) $1,500 per person $3,000 per family (2 or more members) Annual Maximum Benefit None None Office Visit most primary and specialty care consultations, exams and treatment 100% after $10 copay 100% after $10 copay Preventive/Wellness Care 100% 100% Scheduled Prenatal Care 100% after $10 copay 100% Urgent Care 100% after $15 copay 100% after $10 copay Emergency Room Visit 100% after $50 copay 100% after $35 copay Ambulance 100% 100% Outpatient Surgery 100% $10 copay Outpatient X-Ray and Lab 100% 100% Hospitalization including inpatient surgery 100% after $250 copay 100% after $250 copay Mental Health Treatment Inpatient 100% after $250 copay 100% after $250 copay Outpatient Substance Abuse Treatment 100% after $10 copay 100% after $10 copay (individual visit) 100% after $5 copay (group visit) Inpatient 100% after $250 copay 100% after $250 copay Outpatient Home Health Care Skilled Nursing Facility Care 100% after $10 copay 100% after $10 copay, limited to 100 visits per year 100% after $250 copay, limited to 100 days per year 100% after $10 copay (individual visit) 100% after $5 copay (group visit) 100% limited to 100 visits per year 100% limited to 100 days per year Hospice Care 100% 100% Durable Medical Equipment 100% 100% Prescription Drugs Retail (up to a 30-day supply) Retail (up to a 30-day supply) Generic Drugs 100% after $10 copay 100% after $15 copay Brand Name Drugs 100% after $30 copay 100% after $30 copay Mail (up to a 90-day supply) Mail (31-day to 100-day supply) Generic Drugs 100% after $20 copay 100% after $30 copay Brand Name Drugs 100% after $60 copay 100% after $60 copay 10

11 SUMMARY OF BENEFITS DENTAL OPTIONS The following is a summary of the benefits payable under each Dental Benefit option. Benefits under Coast Dental Group, Dental Health Services/Universal Care, and United Concordia options are provided through a contract between UNITE HERE HEALTH and the dental HMO. See the certificate of coverage for details about the coverage paid under each HMO. If there are any conflicts between this summary and the contract with the HMO, the terms of the contract will govern. Description of Services Alternate Dental Plan (Maximum Reimbursement) Coast Dental Group Dental Health Services United Concordia Employee Dependent Annual Maximum Benefit None $400/person None None None Routine Oral Exams $4.50 $ % 100% 100% X-Rays $1.50 single film $0.75 each additional film $1.10 single film $0.55 each additional film 100% 100% 100% Prophylaxis $6.75 $ % 100% 100% Topical Application of Fluoride $9.00 $ % 100% 100% Space Maintainers $ $20.00 Not covered 100% 100% 100% Amalgam Restorations $ $11.25 $ $ % 100% 100% Crowns $ $50.00 Not covered Pulp Capping (excludes final restoration) 100% after $35 copay 100% after $35 - $60 copay 100% after $25 - $75 copay $4.50 $ % 100% 100% Periodontal Scaling/Root Planing $9.00 $ % after $20 copay (per quadrant) 100% after $20 copay (per quadrant) 100% Complete Maxillary Denture $77.50 Not covered Rebase Dentures Varies Not covered Removal of Impacted Tooth Soft Tissue Comprehensive Orthodontic Treatment for Teenagers 100% after $55 copay 100% after $30 copay 100% after $55 copay 100% after $30 copay 100% after $100 copay 100% $12.75 $ % 100% 100% Not covered Not covered 100% after $1,800 copay 100% after $1,800 copay 100% after $1,500 copay 11

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13 IN THIS SECTION 13 EMPLOYEES 13 DEPENDENTS 14 ENROLLMENT REQUIREMENTS WHO S ELIGIBLE Employees You are eligible for coverage if: You work for an employer who is required by a Collective Bargaining Agreement to contribute to UNITE HERE HEALTH on your behalf; The necessary contributions are received by UNITE HERE HEALTH; and You satisfy the Plan s eligibility rules. If you are required to make any payment toward the cost of providing coverage for you and your family, you must arrange with your employer to make those payments by payroll deduction. If your employer does not permit payroll deductions, you must submit any payment owed to UNITE HERE HEALTH. Dependents Your dependents become eligible for coverage on the date you become eligible or on the date you acquire the dependent, whichever happens last. Who Your Dependents Are For benefit purposes, your dependents are: Your husband or wife, but only if there is valid documentation (see page 15); Your same-sex or opposite-sex domestic partner, under certain circumstances: contact UNITE HERE HEALTH for details; Your children, including: natural children, step-children, adopted children, children placed with you for adoption and for whom you are legally required to provide support until the adoption is finalized, children entitled to coverage because of a Qualified Medical Child Support Order, or children for whom you are awarded legal guardianship or sole custody pursuant to state domestic relations law, who are under age 26. The information beginning on page 40 will help you figure out when you are eligible for benefits. If your employer does not permit payroll deductions, send payments to: UNITE HERE HEALTH P.O.Box 6557 Aurora, IL Coverage for your dependents can not begin before your coverage begins. If you enroll a domestic partner, you will have to pay any federal, state, or local taxes owed on the value of the domestic partner benefits to UNITE HERE HEALTH on a quarterly basis. Contact UNITE HERE HEALTH with questions about covering domestic partners. To be covered on or after their 26th birthday, your unmarried children must be unable to support themselves because of a mental or physical handicap that began before age 19 and while covered by the Plan on the day prior to their 19th birthday. 13

14 WHO S ELIGIBLE For more information on termination of Dependent Coverage or on continuing coverage for your children over 26, see page 45. Enrollment Requirements Choice of Coverage Options UNITE HERE HEALTH offers two HMO options for medical benefits and prescription drug coverage, and four options for dental benefits three dental HMOs and one indemnity plan. Your required monthly payment, if applicable, is the same regardless of which HMO or dental benefit option you choose. Medical Benefits Options: Kaiser Permanente HMO In some cases, you may be permitted to waive coverage if you have other medical coverage. Please contact UNITE HERE HEALTH for more information about waiving coverage. Health Net HMO Dental Benefits Options The Coast Dental Group United Concordia Plan Dental Health Services/Universal Care Plan Alternate Dental Benefit You may choose either medical HMO option, and any one of the four dental benefits options. Your enrolled dependents will automatically be covered under the same medical and dental benefits options you select. However, if you and your spouse are both employees, you must select the same medical and dental benefits options. Employees You need to fill out an election form, whether or not you are required to contribute to the cost of coverage. The form must be completed and submitted to UNITE HERE HEALTH by the enrollment due dates. Plan benefits will not be paid until a completed form is submitted. If you choose not to enroll, you and your dependents will not be covered. You can enroll later. However, your coverage will not begin until UNITE HERE HEALTH receives your completed election form. Contact UNITE HERE HEALTH for more information about late enrollment and the effective date of coverage for late enrollment. You may also be eligible for a special enrollment period. See page 43 for more information. Once you have Dependent Coverage, you must still enroll newly acquired dependents and submit the required proof to the Aurora, Illinois, UNITE HERE HEALTH Office. Dependents The enrollment form identifies the dependents you want covered and requests: your name, Social Security number, birth date, home address, telephone number, employer s name and address, and the dependent s name, sex, birth date, and Social Security number. The enrollment form must be submitted to UNITE HERE HEALTH within 30 days after the date you become entitled to elect Dependent Coverage. 14

15 WHO S ELIGIBLE Dependent Documentation In order to verify a person s dependent status for benefit purposes, in addition to the completed enrollment form, you must also provide, as appropriate, at least one of the following: A certified copy of your marriage certificate; An affidavit of domestic partnership, if you are enrolling a domestic partner; A commemoration of marriage issued by a generally recognized denomination of organized religion; A certified copy of the birth certificate; Baptismal certificate; Hospital birth records; Written proof of adoption or legal guardianship; Federal law requires UNITE HERE HEALTH to honor Qualified Medical Child Support Orders. UNITE HERE HEALTH has established procedures for determining whether a divorce decree or a support order meets federal requirements and for enrollment of any child named in the Qualified Medical Child Support Order. To obtain a copy of these procedures at no cost, or for more information, contact UNITE HERE HEALTH. Copies of court decrees that obligate an employee to provide medical benefits for a dependent child; Notarized copies of a participant s most recent Federal Income Tax return (Form 1040 or its equivalents); Certificates of Creditable Coverage issued in accordance with the provisions of the Health Insurance Portability and Accountability Act of 1996, as amended; Documentation of dependent status issued and certified by the United States Immigration and Naturalization Service; or English translations for all documents must be provided as required. Documentation of dependent status issued and certified by a foreign embassy. If any of the above documents are used to verify the dependent status of a child, they must contain the names of the child s parents. 15

16 IN THIS SECTION 16 HOW DO I USE A MEDICAL HMO? 16 HOW THE MEDICAL HMO CONTRACT AFFECTS YOUR BENEFITS MEDICAL BENEFITS OPTIONS See the Summary of Benefits for a description of the benefits provided under each medical HMO option. To reach Kaiser Permanente, visit or call (800) To reach Health Net, visit or call (800) If you select Health Net as your medical HMO, except for urgent or emergency care, you can only receive benefits for care provided in the state of California even if you or a dependent lives outside the state. UNITE HERE HEALTH has contracted with two medical health maintenance organizations (HMOs) Kaiser Permanente and Health Net to provide benefits for you and your enrolled dependents. When you become eligible to enroll in UNITE HERE HEALTH, you will receive a welcome packet highlighting the medical HMO benefit options available to you. In order to enroll, you must complete the forms included in the enrollment packet. How Do I Use a Medical HMO? Once you enroll in a medical HMO, you may be required to choose a primary care doctor. Even if the medical HMO does not require you to pick a primary care doctor, you may choose to do so. You can choose any available primary care doctor in the network. You may choose a pediatrician as a child s primary care physician. Your primary care doctor will help you get care. For example, you may need a referral to see most specialists. Your primary care doctor can do this for you. However, if you are female, you do not need prior authorization or a referral to see a contracted health care professional that specializes in obstetrics or gynecology. Except in emergencies, you will usually be required to use an HMO doctor, HMO hospital, or HMO facility in order to receive benefits. You can get more information about your medical HMO benefits by calling either Kaiser Permanente or Health Net, whichever medical HMO you select. How the Medical HMO Contract Affects Your Benefits The contract between UNITE HERE HEALTH and the applicable medical HMO governs how benefits are paid under either the Kaiser Permanente HMO or the Health Net HMO. If there is any discrepancy between any information described in this book and the contract between the applicable medical HMO and UNITE HERE HEALTH, the contract will govern. 16

17 MEDICAL BENEFITS OPTIONS In addition, these contracts govern how medical HMO benefits are paid and administered. That means that the certificate of coverage you get when you enroll in either HMO option will explain the rules that apply to your benefits. Several sections of this SPD do not apply to the medical HMO benefits you receive through either Kaiser Permanente or Health Net, including: Subrogation; Coordination of Benefits; General Claim Provisions. The benefit booklet you receive from either Kaiser Permanente or Health Net will give you more information about your medical management programs, your medical and prescription drug benefits, coordination of benefits, exclusions and limitations, subrogation, and claims provisions, including filing claim appeals. 17

18 IN THIS SECTION 18 ALTERNATE DENTAL BENEFIT 21 DENTAL BENEFITS AFTER ELIGIBILITY ENDS 22 SCHEDULE OF BENEFITS UNDER THE ALTERNATE DENTAL BENEFIT DENTAL BENEFITS OPTIONS See the Summary of Benefits for a description of the benefits provided under each dental HMO option. Retirees and their dependents are not eligible for Dental Benefits. You have your choice of four options: Coast Dental Group; United Concordia Plan; Dental Health Services/Universal Care Plan; or Alternate Dental Benefit. If you choose the Coast Dental Group, the United Concordia Plan, or the Dental Health Services/Universal Care Plan, see the applicable brochure for more information about your benefits. UNITE HERE HEALTH contracts with each of these dental HMOs to provide benefits to employees and their dependents. The contracts govern the Dental Benefits provided through each dental HMO. Alternate Dental Benefit What the Plan Pays If you or a dependent incurs covered dental expenses, the Plan will reimburse you for the dentist s charge, up to the maximum benefit listed in the Alternate Dental Benefit Schedule of Benefits (beginning on page 22). The Plan will pay this benefit directly to you. Benefits for dependents are limited to $400 per year. The maximum benefit does not apply to routine exams provided to children under age 19. Benefits for temporomandibular joint disorder (TMJ) treatment is limited to a lifetime maximum benefit of $500 per person. What You Pay You are responsible for paying any charges the Plan does not pay, including the difference between the dentist s actual charges and the maximum allowable benefit or services that are not considered a covered dental expense. 18

19 DENTAL BENEFITS Pre-determination of Benefits If a dentist estimates that charges for proposed non-emergency treatment will total more than $300, you or your dentist must submit a request for pre-determination to the Aurora regional office. The request for pre-determination of benefits should include your name, the patient s name, the dentist s name, a detailed proposed treatment plan, and an itemized list of estimated costs. UNITE HERE HEALTH will review the proposed treatment plan and determine what the Fund will pay for the treatment. If you don t request a pre-determination of benefits, UNITE HERE HEALTH may limit benefits to $300 or to the maximum benefit for the least expensive alternate course of treatment. Your claim may also be denied in its entirety. Alternate Course of Treatment If your dentist submits a request for pre-determination of benefits, and UNITE HERE HEALTH determines that an alternate method of treatment would be at least as effective, but less costly, Dental Benefits may be paid based on the alternate method provided the alternate treatment is: Commonly used in the treatment of the existing condition, as determined by UNITE HERE HEALTH s dental consultant; and Recognized by the dental profession to be appropriate in accordance with accepted nation-wide standards of dental practice. Medically Necessary Care and Treatment Medically necessary care and treatment means services, supplies, or places where dental treatment is received which: Are consistent with and effective for the injury or sickness being treated; Constitute good dental practice according to professional standards recognized by the organized medical community in the United States; and Are neither experimental, investigational, nor unproven as determined by appropriate governmental agencies, the organized medical community in the United States, or standards or procedures adopted from time-to-time by the Trustees. The Board of Trustees has the sole authority to determine what constitutes medically necessary care and treatment, and experimental or investigational procedures. In all cases, the Trustees determination will be final and binding. However, those determinations are solely for the purpose of establishing what services or courses of treatment are covered by the Plan. All decisions regarding treatment are between you and your dentist and should be based on all appropriate factors, only one of which is the level of benefits available under the Plan. Submit claims or requests for Predetermination of Benefits to: UNITE HERE HEALTH P.O. Box 6557 Aurora, IL Pre-determination of benefits does not guarantee eligibility for benefits. An allowable charge is the amount upon which benefits are based for covered treatment, services, or supplies. The Board of Trustees has the sole authority to determine the level of allowable charges the Plan will use, and in all cases, the Trustees determination will be final and binding. The Plan will not consider any amount exceeding the allowable charge for a particular service or supply to be a covered expense. A dentist is a person who is duly licensed to practice dentistry or perform oral surgery in the state in which he or she is practicing, and who is acting within the scope of that license. For the purpose of this definition, a doctor will be considered to be a Dentist when performing a covered dental service and is operating within the scope of his or her license. 19

20 DENTAL BENEFITS Experimental, investigative, or unproven procedures are those which are classified that way by agencies or subdivisions of the federal government such as the Food and Drug Administration (FDA) or the Office of Health Technology Assesment of the Centers for Medicare & Medicaid Services (CMS), or according to CMS s Medicare Coverage Issues Manual. What s Covered Dental services listed in the Alternate Dental Benefit Schedule of Benefits include treatment necessary for: Preventive care; Treatment of dental disease or defect; or Treatment of accidental injury. What s Not Covered No Dental Benefits are provided for: Charges incurred before coverage begins; With respect to dependents only, charges for: the initial placement or the replacement of a prosthetic device (including crowns and inlays that form abutments), For the addition of teeth to a denture or bridgework if the placement, replacement or addition is made to replace teeth, all of which were extracted while the covered person was not eligible for the Alternate Dental Benefit, or Any major dentistry listed as not covered in the Alternate Dental Benefit Schedule of Benefits on pages Replacement of lost or stolen appliances or devices; Replacement of, or addition of teeth to, a denture or bridgework unless satisfactory evidence is given to UNITE HERE HEALTH that: the replacement or the addition of teeth is made to replace, for the first time, one or more natural teeth extracted while you were covered under the Alternate Dental Benefit, the existing denture or bridgework was installed at least five years prior to its replacement and cannot be repaired to meet professionally recognized standards, or the existing denture is an immediate temporary denture that requires replacement by a permanent denture, but only if the replacement is delivered or installed within 12 months after the date the temporary denture was installed; Orthodontic services; For a procedure that is performed mainly to improve the appearance of the covered person; For facing on a crown when the crown is on a tooth behind the second bicuspid; For specialized techniques that involve precision dentures for personalization or characterization; For services rendered by any provider who is a covered person under this Plan, or is the spouse, parent, child, brother or sister of a covered person; 20

21 DENTAL BENEFITS Services: that are not necessary and/or customary as determined by the standards of generally accepted dental practice, for which no valid dental need can be demonstrated, or that are experimental or investigational in nature; Any injury, sickness, or dental or vision treatment which arises out of or in the course of any occupation or employment, or for which a person has received or is entitled to receive benefits under a workers compensation or occupational disease law, whether or not application has been made or approved for such benefits; Any treatment, services, or supplies: for which no charge is made, for which a person is not required to pay, or which are furnished by or payable under any plan or law of a federal or state government entity, or provided by a county, parish, or municipal hospital when there is no legal requirement to pay for such treatment, services, or supplies; Any expense or charge for failure to appear for an appointment as scheduled, or charge for completion of claim forms, or finance charges; Any treatment, services, or supplies purchased or provided outside the 50 United States of America, unless for the treatment of a medical emergency. The decision of the Trustees in determining the emergency will be final; Any charges incurred for treatment, services, or supplies as a result of a declared or undeclared war or any act thereof; or any loss, expense or charge incurred while a person is on active duty or in training in the Armed Forces, National Guard, or Reserves of any state or any country; Any injury or sickness resulting from participation in an insurrection or riot, or participation in the commission of a felonious act or assault; Any expense greater than the Plan s maximum benefits, or any expense incurred before eligibility for coverage begins or after eligibility terminates, unless specifically provided for under the Plan. Dental Benefits After Eligibility Ends If coverage ends because of the loss of eligibility for reasons other than termination of UNITE HERE HEALTH, benefits will only be determined for allowable charges incurred for treatment that is rendered while you are covered under the Alternate Dental Benefit, and is competed within 30 days of the date your coverage under the Alternate Dental Benefit ends. If coverage ends because the Plan terminates, in whole or in part, no benefits will be available for claims submitted after coverage ends. 21

22 DENTAL BENEFITS Schedule of Benefits Under the Alternate Dental Benefit Maximum Allowable Benefit per Procedure Description of Services Employee Dependent The $400 calendar year maximum benefit does not apply to routine exams provided to children under age 19. Calendar year maximum benefit per person n/a $400 Lifetime maximum benefit for TMJ disorder treatment $500 $500 VISITS AND EXAMINATIONS Examination (initial episode of treatment only) $4.50 $3.30 Office visits for medication, observation and temporary correction of accidental injuries to natural teeth or supporting structures (post-operative visits and visits where a permanent corrective procedure is performed are not covered) Professional visit after hours (optional in lieu of allowances for services rendered) Special consultation (allowable for examination by a dental specialist whose advice or opinion is requested by the attending dentist) $3.00 $2.20 $7.50 $5.50 $7.50 $5.50 Prophylaxis adults $6.75 $4.95 Topical application of sodium fluoride one treatment $9.00 $6.00 Topical application of stannous fluoride including prophylaxis (limited to one treatment each 12-month period) Emergency treatment (palliative) each visit (limited to two treatments each 12-month period) $10.50 $7.70 $3.75 $2.75 ROENTGENOLOGY AND PATHOLOGY Single film $1.50 $1.10 Additional films (up to a total of 13 films) $0.75 $0.55 Entire denture series consisting of at least 14 films (including bitewings if indicated) $11.25 $8.25 Intraoral, occlusal view, maxillary, or mandibular each $3.00 $2.20 Superior or inferior maxillary, extraoral, one film $7.50 $5.50 Superior or inferior maxillary, extraoral, two films $11.25 $8.25 Biopsy of oral tissue $6.00 $4.40 Microscopic examination $11.25 $8.25 EXTRACTIONS Initial, per visit, uncomplicated (includes routine post-operative visits) $6.00 $4.40 Each additional tooth, same visit, uncomplicated (includes routine post-operative visits) $4.50 $

23 DENTAL BENEFITS Maximum Allowable Benefit per Procedure (cont.) Description of Services Employee Dependent Surgical removal of erupted teeth $18.75 $13.75 Post-operative visits (including sutures and complications) $2.25 $1.65 IMPACTED TEETH Removal of tooth soft tissue $12.75 $9.35 Removal of tooth partially bony $18.75 $13.75 Removal of tooth completely bony $30.00 $22.00 RESTORATIVE DENTISTRY Amalgam restorations Cavities involving one tooth surface $6.00 $4.40 Cavities involving two tooth surfaces $8.25 $6.05 Cavities involving three or more tooth surfaces $11.25 $8.25 Gold restorations and crowns (not serving as bridge abutments) Gold foil one surface $26.25 $19.25 Gold foil two surfaces $30.00 $22.00 Gold foil three surfaces $37.50 $27.50 Inlay, gold one surface $26.25 $19.25 Inlay, gold two surfaces $30.00 $22.00 Inlay, gold three surfaces $37.50 $27.50 Inlay (per tooth) in addition to above $7.50 $5.50 Silicate, acrylic and plastic restorations silicate cement filling $6.75 $4.95 ENDODONTICS Acrylic or plastic fillings $8.25 $6.05 Pulp capping $4.50 $3.30 Therapeutic pulpotomy in addition to restoration each treatment $4.50 $3.30 Vital pulpotomy $9.00 $6.60 Remineralization each tooth (CaOH temporary restoration) $7.50 $5.50 Root canal culturing canal $5.25 $3.85 Root canal single root canal therapy $33.75 $24.75 Bi-rooted tooth canal therapy $45.00 $33.00 Tri-rooted tooth canal therapy $56.25 $41.25 Apicoectomy (including filling of root canal) $37.50 $27.50 Apicoectomy (separate procedure) $26.25 $

24 DENTAL BENEFITS Maximum Allowable Benefit per Procedure (cont.) Description of Services Employee Dependent PERIODONTICS Emergency treatment periodontal abscess, acute periodontitis, etc. (allowable for initial episode of treatment only) $7.50 $5.50 Subgingival curettage root planing $9.00 $6.60 Correction of occlusion $9.00 $6.60 Gingivectomy each quadrant (including post-surgical visits) $37.50 $27.50 Gingivectomy, osseous or muco-gingival surgery each quadrant (including post-surgical visits) $45.00 $33.00 Gingivectomy, treatment each tooth (fewer than 6 teeth) $7.50 $5.50 ALVEOLAR OR GINGIVAL RECONSTRUCTION Alveolectomy (edentulous) each quadrant $18.75 $13.75 Alveolectomy (in addition to removal of teeth) each quadrant $7.50 $5.50 Alveoplasty with ridge extension, each arch $31.50 $23.10 Removal of palatal torus $26.25 $19.25 Removal of mandibular tori each quadrant $26.25 $19.25 Excision of hyperplastic tissue each arch $24.00 $17.60 CYSTS AND NEOPLASMS Intraoral incision and drainage of abscess $7.50 $5.50 Extraoral incision and drainage of abscess $11.25 $8.25 Excision pericoronal gingival $7.50 $5.50 Sialolithotomy: removal of salivary calculus, extraorally $75.00 $55.00 Sialolithotomy: removal of salivary calculus, intraorally $24.75 $18.15 Closure of salivary fistula $45.00 $33.00 Dilation of salivary duct $12.75 $9.35 Resection of benign tumor of soft tissue (2.5 cm or larger) $18.75 $13.75 Resection of malignant tumor TBD TBD Transplantation of tooth or tooth bud $52.50 $38.50 Removal of foreign body from bone independent procedure TBD TBD Maxillary sinusotomy to remove tooth fragment or foreign body $48.75 $35.75 Closure of oral fistula or maxillary sinus $30.00 $22.00 Excision of cyst, small $18.75 $13.75 Excision of cyst, large (2.5 cm or larger) $56.25 $41.25 Sequestrectomy for osteomyelitis or bone abscess, superficial $15.00 $11.00 Condylectomy of temporomandibular joint $ $ Meniscectomy of temporomandibular joint $ $ Radical resection of bone for tumor with bone graft TBD TBD 24

25 DENTAL BENEFITS Maximum Allowable Benefit per Procedure (cont.) Description of Services Employee Dependent MISCELLANEOUS Incision and removal of foreign body from soft tissue $7.50 $5.50 Frenectomy $18.75 $13.75 Suture of soft tissue wound or injury $7.50 $5.50 Crown exposure for orthodontia $11.25 $8.25 Injection of sclerosing agent into temporomandibular joint $22.50 $16.50 Treatment of trigeminal neuralgia by injection into second and third divisions $25.50 $18.70 Peripheral nerve block, breaches of fifth cranial $4.50 $3.30 Drugs antibiotic injection $3.75 $2.75 General anesthesia (allowable only if not hospital confined) $11.25 $8.25 GOLD RESTORATION Allowances shown below are for gold restorations other than crowns on abutment teeth One tooth surface $15.00 Not covered Two tooth surfaces $20.00 Not covered Three or more tooth surfaces $25.00 Not covered Onlays, additional per tooth $5.00 Not covered CROWNS No allowance is made for facings on crowns, posterior to 2nd bicuspids Acrylic $30.00 Not covered Acrylic with metal $37.50 Not covered Porcelain with metal $50.00 Not covered Porcelain $37.50 Not covered Gold (full) $32.50 Not covered 3/4 gold $30.00 Not covered Stainless steel (primary) $8.50 Not covered Stainless steel (permanent) $10.00 Not covered Gold dowel pin $5.00 Not covered PONTICS Cast gold (sanitary) $20.00 Not covered Steele s facing $22.50 Not covered Tru-pontic type $27.50 Not covered Porcelain baked to gold $40.00 Not covered Porcelain processed to gold $27.50 Not covered 25

26 DENTAL BENEFITS Maximum Allowable Benefit per Procedure (cont.) Description of Services Employee Dependent REMOVABLE (UNILATERAL) BRIDGES One piece casting, chrome cobalt alloy clasp attachment (all types) per unit, including pontics $10.00 Not covered RECEMENTATION Inlay $2.50 Not covered Crown $2.50 Not covered Bridge $5.00 Not covered REPAIRS, CROWNS & BRIDGES Fee based on time and laboratory charges TBD Not covered DENTURES Dentures, partial dentures and reline fees including adjustments for 6-month period following installation $77.50 Not covered Complete mandibular denture $77.50 Not covered Partial acrylic upper or lower with gold or chrome cobalt alloy clasps base fee $37.50 Not covered Teeth and clasps extra, per unit $2.50 Not covered Partial lower or upper with chrome cobalt alloy lingual or palatal bar and acrylic saddles base fee $75.00 Not covered Teeth and clasps extra, per unit $2.50 Not covered Stayplate base fee $15.00 Not covered Teeth and clasps extra, per unit $1.50 Not covered Immediate splint denture $35.00 Not covered Denture adjustments $2.00 Not covered Office reline cold cure acrylic $7.50 Not covered Special tissue conditioning per denture, in addition to reline maximum $17.50 Not covered 2 per denture $7.50 Not covered Denture duplication (jump case) per denture $27.50 Not covered Simple stress breakers extra $7.00 Not covered REPAIRS, DENTURES, ACRYLIC Broken denture, repairing (no teeth involved) $6.00 Not covered Replacing missing or broken teeth, each additional $1.50 Not covered Adding teeth to partial denture to replace extracted natural teeth first tooth $12.50 Not covered First tooth with clasp $15.00 Not covered Each additional tooth and clasp $2.50 Not covered Partial denture repairs based on time and laboratory charges TBD Not covered 26

27 DENTAL BENEFITS Maximum Allowable Benefit per Procedure (cont.) Description of Services Employee Dependent SPACE MAINTAINERS Fee includes all adjustments within six months following installation Fixed space maintainer (band type) $17.50 Not covered Removable acrylic space maintainer With stainless steel round wire rest only $20.00 Not covered Stainless steel clasps and/or activating wires, in addition per wire or clasp $2.50 Not covered Office visit for observation, adjustment and activation per visit $2.00 Not covered Study models $2.50 Not covered Removable inhibiting appliance to correct thumb sucking $20.00 Not covered Office visit for observation, adjustment and activation per visit $2.00 Not covered Fixed or cemented inhibiting appliance to correct thumb sucking $20.00 Not covered Office visit for observation, adjustment and activation per visit $2.00 Not covered The maximum allowable benefit per procedure for the services and supplies labelled TBD in the table on the previous pages will be determined based upon the nature and extent of the service performed. 27

28 IN THIS SECTION 28 WHAT S COVERED 29 WHAT THE PLAN PAYS 29 WHAT YOU PAY 29 WHAT S NOT COVERED VISION CARE BENEFITS Retirees and their dependents are not eligible for Vision Care Benefits. Send claims for Vision Care Benefits to: UnitedHealthcare Vision Claims Department P. O. Box Salt Lake City, UT Customer service number: (800) fax: (248) Vision Care Benefits are provided through an insurance contract with UnitedHealthcare. If there are any conflicts between the insurance contract and the plan documents, the contract shall govern. The level of benefits are based on whether you use a network provider or a non-network provider. Generally, the highest level of benefits applies to covered services furnished by UnitedHealthcare network providers. To locate a network provider near you, contact UnitedHealthcare Vision toll free (800) What s Covered The following services and supplies are available to you or a covered dependent when furnished by a licensed vision professional: A routine eye examination performed by a state-licensed optometrist or ophthalmologist; Standard lenses, including scratch-resistant coating: single vision, bifocal lenses, trifocal lenses, or lenticular lenses; Frames, up to a $50 wholesale allowance or a $130 retail allowance; and Elective or medically necessary contact lenses, including fitting and evaluation, and up to two follow-up visits. Elective contact lenses are subject to a maximum $105 allowance for all materials, fittings and evaluations. 28