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DELTA DENTAL PPO PLUS PREMIER COMPREHENSIVE ENHANCEDwith Orthodontic CoverageDental Benefit Plan SummaryNorth Dakota Public Employees Retirement SystemGroup Number 537482CompEnh2017
DENTAL BENEFIT PLAN SUMMARYThis is a Summary of your Group Dental Program(PROGRAM) prepared for Covered Persons with:North Dakota Public Employees Retirement System(GROUP)This Program has been established and is maintained and administered in accordance with the provisions ofyour Group Dental Plan Contract Number 537482 issued by Delta Dental of Minnesota (PLAN).This booklet is subject to the provisions of the Group Dental Plan Contract. If there is an inconsistencybetween this booklet and the Group Dental Plan Contract, the Group Dental Plan Contract controls.RIGHT TO INSPECT: As a participant in the Program, you are entitled to examine without charge at the GroupAdministrator’s office and at other specified locations such as work sites, all Contract documents, including theGroup Dental Contract applicable to this coverage. Contact your Group Administrator to make arrangementsfor a mutually agreeable time and location to review such Contract documents.DELTA DENTAL OF MINNESOTAAdministrative OfficesDelta Dental of MinnesotaNational Dedicated Service CenterP.O. Box 59238Minneapolis, Minnesota 55459(651) 406-5901 or (800) 448-3815www.deltadentalmn.orgCompEnh2017
DELTA DENTAL OF MINNESOTANOTICE OF INFORMATION PRACTICESTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED ANDDISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW ITCAREFULLY.Delta Dental of Minnesota is required by law to maintain the privacy of your Protected HealthInformation, to provide you with this notice of its legal duties and privacy practices with respect toyour Protected Health Information and to notify you following a breach of unsecured ProtectedHealth Information. This notice is being issued to comply with the requirements of the Privacy Rulesunder the Health Insurance Portability and Accountability Act (“HIPAA Privacy Rules”). Individuallyidentifiable information about your past, present or future health or condition, the provision of healthcare to you, or payment for such health care is considered “Protected Health Information” (“PHI”).Health care includes dental care.Our Permitted Uses and Disclosures of Your Protected Health InformationWe use and disclose PHI about you without your authorization for treatment, payment, and health careoperations.Treatment: We may disclose PHI to your dentist(s) for treatment purposes. For example, your dentist maywish to provide a dental service to you but first seek information from us as to whether the service has beenpreviously provided.Payment: We use and disclose your PHI in order to fulfill our duty to provide your coverage, determine yourbenefits, and make payment for services provided to you. For example, we use and disclose your PHI in orderto process your claims.Health Care Operations: We use and disclose your PHI as a part of certain operations, such as qualityimprovement. For example, we may use and disclose your PHI to evaluate the quality of dental services thatwere performed or to check for fraud and abuse.We may not, however, use or disclose any PHI that is considered genetic information under Federal Law forunderwriting purposes.We may be asked by the sponsor of your dental benefits to provide your PHI to the sponsor. We will do so ifpermitted by law.Unless you object, we may disclose your PHI to a family member, other relative, person authorized by law, orany other person you identify as involved in your care or the payment related to your care. Only PHI relevantto that person’s involvement in your care or the payment related to your care will be disclosed. You canrestrict this disclosure at any time, subject to certain limitations. If you are incapacitated or in the event of anemergency, we will exercise professional judgment to determine whether a disclosure of this type is in yourbest interest.We may also use or disclose your PHI without your authorization for several other reasons. Subject to certainrequirements, we may use or disclose your PHI without your authorization for public health purposes, auditingpurposes, research studies, and emergencies. We may disclose PHI in response to a court or administrativeorder, subpoena, discovery request or other lawful process if certain conditions are met and the requiredassurances are received. We provide PHI when otherwise required by law, such as for law enforcementpurposes. We may disclose your PHI to public health or other appropriate authorities to lessen a serious orimminent threat to the health or safety of you or the public. In other situations not described here, we will askfor your written authorization before using or disclosing your PHI. If you choose to sign an authorization toallow disclosure of your PHI, you can later revoke that authorization to stop any future uses and disclosures(other than for treatment, payment and health care operations).CompEnh2017
We reserve the right to change this notice at any time and for any reason. We reserve the right to make therevised or changed notice effective for PHI we currently maintain as well as any information received in thefuture. A copy of our most current notice will be posted at www.deltadentalmn.org.Individual RightsIn most cases, you have the right to view or get a copy of your PHI which is held in a particular record set byus. You may request copies for a nominal per-page charge. You also have the right to receive a list ofinstances where we have disclosed your PHI without your written authorization for reasons other thantreatment, payment or health care operations. If you believe that information in your record is incorrect or ifimportant information is missing, you have the right to request that we correct the existing information or addthe missing information.You may request in writing that we not use or disclose your PHI for treatment, payment and health careoperations except when specifically authorized by you, when required by law, or in emergency circumstances.We will consider your request but are not legally required to accept it. You also have the right to receiveconfidential communications of PHI by alternative means or at alternative locations, if you clearly state thatdisclosure of all or part of your PHI could endanger you. You also have the right to receive notice following anunauthorized access, use or disclosure of your PHI if that unauthorized access, use or disclosure is considereda “breach” as defined by the HIPAA Privacy Rules.ComplaintsIf you are concerned that we have violated your privacy rights, or you disagree with a decision we have madeabout access to your records, you may contact the address listed below. You may also send a writtencomplaint to the U.S. Department of Health and Human Services. The person listed below can provide youwith the appropriate address upon request.Our Legal DutyWe are required by law to protect the privacy of your information, provide this notice about our informationpractices, and follow the information practices that are described in this notice.If you wish to inspect your records, receive a listing of disclosures, or correct or add to the information in yourrecord, request a paper copy of this Notice or if you have any questions, complaints or concerns, pleasecontact:National Dedicated Service CenterP.O. Box 59238Minneapolis, Minnesota 55459(651) 406-5901 or (800) 448-3815CompEnh2017
Notice of Non-Discrimination and Accessibility RequirementsDelta Dental of Minnesota complies with applicable Federal civil rights laws and does not discriminate on thebasis of race, color, national origin, age, disability, or sex.Delta Dental of Minnesota does not exclude people or treat them differently because of race, color, nationalorigin, age, disability, or sex.Delta Dental of Minnesota provides free aids and services to people with disabilities to communicateeffectively with us, such as: Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)Delta Dental of Minnesota provides free language services to people whose primary language is not English,such as: Qualified interpretersInformation written in other languagesIf you need these services, please call the number on the back of your ID cardIf you believe that Delta Dental of Minnesota has failed to provide these services or discriminated in anotherway on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by contactingDelta Dental of Minnesota, Attn: Complaints, Appeals, and Grievances, 500 Washington Ave South, Suite2060 Minneapolis, MN, 55415, 612-224-3300 or 877-268-3384, fax:612-351-5104. You can file a grievancein person or by mail, fax, or email. If you need help filing a grievance, please call the number on the back ofyour ID card.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office forCivil Rights, electronically through the Office for Civil Rights Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and HumanServices 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-3681019, 800-537-7697 (TDD) Complaint forms are available at ign Language NotificationsATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1800-553-9536. (Spanish)LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-800553-9536. (Hmong)XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama.Bilbilaa 1-800-553-9536. (Cushite)CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-5539536. �� 1-800-553-9536. (Chinese)ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.Звоните 1-800-553-9536. (Russian)ໂປດຊາບ: ຖ້ າວ່ າທ່ ານເວໍ ິ ລການຊ່ ວຍເຫ້ ານພາສາ, ໂດຍບໍ່ ເສ່ າ, ແມ່ ນມ້ ອມໃຫ້ ທ່ ານ. ໂທຣື ຼ ອດີ ພັ ຽຄົ ້ າພາສາ ລາວ, ການບ1-800-553-9536. (Laotian)ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800553-9536. (Amharic)ymol.ymo; erh uwdRAunDAusdmtCdAusdmtw rRpXRvXAwvXmbl.vXmphRAeDwrHRb.ohM. vDRIAud; 1800-553-9536. (Karen)ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zurVerfügung. Rufnummer: 1-800-553-9536. (German) ملحوظ ة : اللغ ة اذك ر تتح دث كن ت إذا ، بالمج ان ل ك تتواف ر ةیاللغ و المس اعدة خدمات ف إن . ب رقم اتص ل 1-800-553-9536) رق م . (Arabic)ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.Appelez le 1-800-553-9536. (French)주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-553-9536 번으로전화해 주십시오. (Korean)CompEnh2017
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nangwalang bayad. Tumawag sa 1-800-553-9536. (Tagalog) یئاگ ادار : تیک ھەد قھس ھ یک ورد یزمان ب ھ ئھگھ ر ، زمان یارمھتی یھک انیخ زمھتگوزار ، ي یاۆڕبھ خ ، ( ۆت ۆب Kurdish) س تھەبھ رد . . بک ھ 1- 800-553-9536 پ ب ھ توج ھ : و یف ارس زب ان ب ھ اگ ر دیک ن یم گفتگ ، ش ما یب را نگ ایرا بص ورت یزب ان التیتس ھ . دیریب گ (Persian / Farsi) تم اس 1-800-553-9536 ب ا . ف یم باش د ��ださい。(Japanese)ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-800553-9536. (Bantu)KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 1-800553-9536. (Swahili)MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 1-800-553-9536.(Norwegian)សូ មរប ុងរបយ័តន: របសិនេបើអនកនិយាយ [ភាសាែខម រ], �ឥតគិតៃថល, ែដលអន �សូ មេហៅទូ រស័ពទ 1-800-553-9536. (Cambodian/Khmer)यानाकषर्ण: यिद तपाईं [नेपाली] बो नहु ु छ भने, िन:शु क पमा तपाईंलाई भाषा सहायता सेवाह उपल ध छन ्। 1800-553-9536 मा कल गनहुर् ोस ्। (Nepali)CompEnh2017
TABLE OF CONTENTSSUMMARY OF DENTAL BENEFITS . 1Copayment Percentage of Coverage . 1Maximums and Deductibles . 1Coverage Year . 1DESCRIPTION OF COVERED PROCEDURES . 2Pretreatment Estimate . 2Benefits . 2Exclusions . 12Limitations . 14Post Payment Review . 14Optional Treatment Plans . 14ELIGIBILITY . 14Employee . 14Dependents . 14Effective Dates of Coverage . 15Open Enrollment. 15Family Status Change . 16Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). 16Termination of Coverage . 17Continuation of Coverage . 17PLAN PAYMENTS . 19Participating Dentist Network . 19Covered Fees . 20Notice of Claim . 20Claim Payments . 20Coordination of Benefits (COB) . 21Time of Payment of Claim . 21Assignment of Benefits . 21Claim and Appeal Procedures . 22GENERAL INFORMATION . 23Health Plan Issuer Involvement . 23Privacy Notice . 23Change of Beneficiary . 23How to Find a Participating Dentist . 24Using Your Dental Program. 24Cancellation and Renewal . 25Physical Examination and Autopsy . 25Time Limit on Certain Defenses . 25CompEnh2017
SUMMARY OF DENTAL BENEFITSAfter you have satisfied the deductible, if any, your dental program pays the following percentages of thetreatment cost, up to a maximum fee per procedure. The maximum fee allowed by Delta Dental is differentfor participating dentists and nonparticipating dentists. If you see a nonparticipating dentist, your out-ofpocket expenses may increase.DeltaDentalPPODiagnostic and Preventive Services . 100%DeltaDentalPremierOut-ofNetwork100%100%Basic Services. 80%80%80%Endodontics. 80%80%80%Periodontics. 80%80%80%Oral Surgery. 80%80%80%Major Restorative Services . 50%50%50%Prosthetic Repairs and Adjustments . 80%80%80%Prosthetics. 50%50%50%Orthodontics. 50%50%50%Benefit MaximumsThe Program pays up to a maximum of 1,000.00 for each Covered Person per Coverage Year subject to thecoverage percentages identified above. Benefit Maximums may not be carried over to future coverage years.Orthodontics is subject to a separate lifetime maximum of 1,500.00 per Covered Person and limited to thoseorthodontic treatment plans commenced on or after the Eligible Covered Person’s eighth (8th) birthday.Because orthodontic treatment normally occurs over a long period of time, benefit payments are made overthe course of treatment. The Covered Person must remain eligible under the Plan in order to receivecontinued benefit payments.DeductibleThere is a 50.00 deductible per Covered Person each Coverage Year.The deductible does not apply to Diagnostic and Preventive or Orthodontic Services.Coverage YearA Coverage Year is a 12-month period in which deductibles and benefit maximums apply. Your CoverageYear is January 1 through December 31.1CompEnh2017
DESCRIPTION OF COVERED PROCEDURESPretreatment Estimate(Estimate of Benefits)IT IS A GOOD IDEA TO GET A PRETREATMENT ESTIMATE FOR YOUR DENTAL CARE THATINVOLVES MAJOR RESTORATIVE, PERIODONTICS, PROSTHETICS OR ORTHODONTIC CARE. THEPRETREATMENT IS RECOMMENDED, BUT NOT REQUIRED FOR YOU TO RECEIVE BENEFITS FORCOVERED DENTAL CARE. THE PRETREATMENT ESTIMATE IS A VALUABLE TOOL FOR BOTH THEDENTIST AND YOU. SUBMISSION OF A PRETREATMENT ESTIMATE ALLOWS THE DENTIST ANDYOU TO KNOW WHAT BENEFITS YOU HAVE AND IF THE TREATMENT IS COVERED. THEPRETREATMENT ESTIMATE OUTLINES WHAT YOU HAVE TO PAY TO THE DENTIST, SUCH AS COPAYMENTS AND DEDUCTIBLES. IT ALLOWS THE DENTIST AND YOU TO MAKE ANY NECESSARYFINANCIAL ARRANGEMENTS BEFORE YOUR TREATMENT BEGINS. THIS PROCESS DOES NOTPRIOR AUTHORIZE THE TREATMENT NOR DETERMINE ITS DENTAL OR MEDICAL NECESSITY.THE ESTIMATED PAYMENT IS BASED ON YOUR CURRENT ELIGIBILITY AND CONTRACT BENEFITSIN EFFECT AT THE TIME OF THE ESTIMATE. THIS IS AN ESTIMATE ONLY. FINAL PAYMENT WILLBE BASED ON THE CLAIM THAT IS SUBMITTED ONCE THE TREATMENT IS COMPLETED.SUBMISSION OF OTHER CLAIMS, A CHANGE IN ELIGIBILITY, A CHANGE IN YOUR COVERAGE OROTHER COVERAGE YOU HAVE MAY ALTER THE PAYMENT AMOUNTAfter the exam, your dentist will tell you the dental treatment that should be given. If the dental treatmentinvolves major restorative, periodontics, prosthetics or orthodontic care, the dentist should submit a claimform to the Plan for the proposed treatment. The Plan will review and determine if the treatment is coveredand estimate the amount of payment.A Pretreatment Estimate of Benefits statement will be sent to you and your dentist. You will be responsibleto pay for any deductibles and coinsurance amounts. You will also be responsible to pay for any dentaltreatment that is not considered a covered service under the Plan.BenefitsThe Program covers the following dental procedures when they are performed by a licensed dentist andwhen necessary and customary as determined by the standards of generally accepted dental practice. Thebenefits under this Program shall be provided whether the dental procedures are performed by a dulylicensed physician or a duly licensed dentist, if otherwise covered under this Program, provided that suchdental procedures can be lawfully performed within the scope of a duly licensed dentist.As a condition precedent to the approval of claim payments, the Plan shall be entitled to request andreceive, to such extent as may be lawful, from any attending or examining dentist, or from hospitals in whicha dentist's care is provided, such information and records relating to a Covered Person as may be requiredto pay claims. Also, the Plan may require that a Covered Person be examined by a dental consultantretained by the Plan in or near the Covered Person's place of residence. The Plan shall hold suchinformation and records confidential.TO AVOID ANY MISUNDERSTANDING OF BENEFIT PAYMENT AMOUNTS, ASK YOUR DENTISTABOUT HIS OR HER NETWORK PARTICIPATION STATUS WITHIN YOUR DELTA DENTAL PPO ANDDELTA DENTAL PREMIER NETWORKS PRIOR TO RECEIVING DENTAL CARE.Delta Dental of Minnesota does not determine whether a service submitted for payment or benefitunder this Plan is a dental procedure that is dentally necessary to treat a specific condition orrestore dentition for an individual. Delta Dental of Minnesota evaluates dental proceduressubmitted to determine if the procedure is a covered benefit under your dental plan. Your dentalPlan includes a preset schedule of dental services that are eligible for benefit by the Plan. Yourdentist may recommend or prescribe other dental care services that are not covered, are cosmeticin nature, or exceed the benefit frequencies of this plan. While these services may be necessary2CompEnh2017
for your dental condition, they may not be covered by us. There may be an alternative dental careservice available to you that is covered under your plan. These alternative services are calledoptional treatments. If an allowance for an optional treatment is available, you may apply thisallowance to the initial dental care service prescribed by your dentist. You are responsible for anycosts that exceed the allowance, in addition to any coinsurance or deductible you may have.Services that are not covered by the Plan or exceed the frequency of Plan benefits do not imply thatthe service is or is not dentally necessary to treat your specific dental condition. You areresponsible for dental services that are not covered or benefited by the Plan. The decision as towhat dental care treatment is best for you is solely between you and your dentist.ONLY those services listed are covered. Deductibles and maximums are listed under the Summaryof Dental Benefits. Services covered are subject to the limitations within the Benefits, Exclusionsand Limitations sections described below. For estimates of covered services, please see the“Pretreatment Estimate” section of this booklet.PREVENTIVE CARE(Diagnostic & Preventive Services)Oral Evaluations - Any type of evaluation (checkup or exam) is covered 2 times per calendar year period.NOTE: Comprehensive oral evaluations will be benefited 1 time per dental office, subject to the 2 timesper calendar year period limitation. Any additional comprehensive oral evaluations performed by thesame dental office will be benefited as a periodic oral evaluation and will be subject to the 2 times percalendar year period.Radiographs (X-rays) Bitewings - Covered at 2 series of films per calendar year period. Full Mouth (Complete Series) or Panoramic - Covered 1 time per 36-month period. Periapical(s) - 4 single X-rays are covered per 12-month period. Occlusal - Covered at 1 series per 12-month period.Dental Cleaning Prophylaxis - Covered 2 times per calendar year period.Prophylaxis is a procedure to remove plaque, tartar (calculus), and stain from teeth.NOTE: A prophylaxis performed on a Covered Person under the age of 14 will be benefited as a childprophylaxis. A prophylaxis performed on a Covered Person age 14 or older will be benefited as anadult prophylaxis. Periodontal Maintenance - Covered 2 times per calendar year period.Periodontal Maintenance is a procedure that includes removal of bacteria from the gum pocket areas,scaling and polishing of the teeth, periodontal evaluation and gum pocket measurements for patientswho have completed periodontal treatment.Fluoride Treatment (Topical application of fluoride) - Covered 1 time per 12-month period for dependentchildren through the age of 18.3CompEnh2017
Oral Hygiene Instructions - Instructions which include tooth-brushing techniques, flossing and use of oralhygiene aids are covered 1 time per lifetime.Sealants or Preventive Resin Restorations - Any combination of these procedures is covered 1 time per36-month period for permanent first and second molars of eligible dependent children through the age of15.Space Maintainers - Covered 1 time per lifetime on eligible dependent children through the age of 16 forextracted primary posterior (back) teeth.LIMITATION: Repair or replacement of lost/broken appliances is not a covered benefit.EXCLUSIONS - Coverage is NOT provided for:1. Restorations placed for preventive or cosmetic purposes.BASIC SERVICESEmergency Treatment - Emergency (palliative) treatment for the temporary relief of pain or infection.Amalgam (silver) Restorations - Treatment to restore decayed or fractured permanent or primary teeth.Composite (white) Resin Restorations Anterior (front) Teeth - Treatment to restore decayed or fractured permanent or primary anteriorteeth. Posterior (back) Teeth - Treatment to restore decayed or fractured permanent or primary posteriorteeth.LIMITATION: Coverage for amalgam or composite restorations will be limited to only 1 service pertooth surface per 12-month period.Other Basic Services Restorative cast post and core build-up, including pins and posts - See benefit coveragedescription under Complex or Major Restorative Services. Pre-fabricated or Stainless Steel Crown - Covered 1 time per 24-month period for eligible dependentchildren through the age of 18.Adjunctive General Services Intravenous Conscious Sedation and IV Sedation - Covered when performed in conjunction withcomplex surgical service.LIMITATION: Intravenous conscious sedation and IV sedation will not be covered when performedwith non-surgical dental care.Denture Adjustments - Covered 2 times per 12-month period: when the prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance;and only after 6 months following initial placement of the prosthetic appliance (denture, partial orbridge).4CompEnh2017
EXCLUSIONS - Coverage is NOT provided for:1. Deep sedation/general anesthesia, analgesia, analgesic agents, anxiolysis nitrous oxide, therapeuticdrug injections, medicines, or drugs for non-surgical or surgical dental care. NOTE: This exclusion willnot apply if the anesthesia is provided to a child who is under age nine, is severely disabled, or whohas a medical condition and requires hospitalization or general anesthesia for dental care treatment.2. Case presentation and office visits.3. Athletic mouthguard, enamel microabrasion, and odontoplasty.4. Services or supplies that have the primary purpose of improving the appearance of the teeth. Thisincludes, but is not limited to whitening agents, tooth bonding and veneers.5. Placement or removal of sedative filling, base or liner used under a restoration.6. Restorations placed for preventive or cosmetic purposes.7. Pulp vitality tests.8. Diagnostic casts.9. Adjunctive diagnostic tests.10. Crowns and indirectly fabricated restorations (inlays and onlays) are not covered unless the tooth isdamaged by decay or fracture with loss of tooth structure to the point it cannot be restored with anamalgam or resin res
Group Dental Contract applicable to this coverage. Contact your Group Administrator to make arrangements for a mutually agreeable time and location to review such Contract documents. DELTA DENTAL OF MINNESOTA Administrative Offices Delta Dental of Minnesota National Dedicated Service Center P.O. Box 59238 Minneapolis, Minnesota 55459
