HomeMy WebLinkAboutHumana Health & Dental 2004City of Jeffersonvil~e
Effective: April 1, 2004
GENERAL INFORMATION:
1. Proper Name of Plan: Ci[y of Jeffersonville Employee Health Plan
2. Legal name of Employer: City of Jeffersonville
(Name provided must match the tax ID number reported to the iRS)
Location Address:
501 East Court Avenue, Room 407
County Building
Jefferson~/ille, IN 47130
Mailing Address: same
Telephone: (812) 285-6405
2a. Multi-Location Yes No N/A
Primary:
Location Address:
Mailing Address:
Telephone:
Fax:
Secondary (variable)
Location Address:
Mailing Address:
Telephone:
Fax:
Tertiary (variable)
Location Address:
Mailing Address;
Telephone:
Fex;
3. Common name of Employer.
Address, only if different Eom above:
City of Jeffersonville
4. Agent for Service of Legal Process:
Name/Title: Leslie Merkley, City Attorney
Address: 501 East Court Avenue, Room 410
Jeffersonville, iN 47130
Telephone: (812) 285-6491
5. Employer Federal ID Number:
35-6001067-01
Updated Apdl 1, 2004 I General information
City of Jeffemonville
Effective: Apdl 1, 2004
GENERAL INFORMATION:
6. Single Employer
Govemment Entry
X Non-Federal Governmental Plan
Church
Other
7. Is the Employer subject to ERISA?
X No
Yes
8. Management Contact:
Name/Title:
Telephone:
Fax Number:
Email Address:
Rob WaizJMayor
(812) 2854400
(812) 285-64O3
mayor~cltyo§eff, net
Kirn Calabro/HR Director
(812) 285-6405
(812) 28~6490
kcala bro@cit yofjeff, net
9. Administrative Contact:
Telephone:
Fax Number:
Email Address:
10. Plan numbers (from 5500 report):
Dental
Other
N/A
11. The Plan is:
X Contributor?
Non-Contributor?
12. Effective Date: April 1, 2004
13. Plan Year (Renewal Year):
14. Fiscal year (Financial Year):
15. Does the Plan include a trust?
Trust Name:
No
Yes
16. Trustees:
Name/Title: N/A
Address:
Name/Title:
Address:
Updated Apdl 1, 2004 2 Genera[ Information
City of Jeffersonville
Effective: April 1, 2004
GENERAL INFORMATION:
17. Plan Sponsor name and address:
City of Jeffemonville
501 East Court Avenue. Room 407
Jeffersonville, IN 47130
18. Plan Administrator and Named Fiduciary:
City of Jeffersonville
501 East Cou~ Avenue, Room 407
Jeffersonville, IN 47130
19. Is this Plan maintained under a collective bargaining agreement?
No
X Yes (for Fire and Police)
20. Subsidiaries and/or affiliates included for coverage: N/A
Legal Name:
Mailing Address:
Contact Name:
Employer Federal ID number:
21. The following person(s) ate authorized to receive protected health information (PHi) (include information
for internal contacts, i.e. management, administrative, financial; external contacts,i.e. Flex Administrator,
Cobra vendor or AgentJBroke riCo nsultent, if applicable).
Name/Title:
Company:
Address:
Telephone:
Fax Number:
Peggy Wilder/Crerk-Treasu ret
City of Jeffersonville
501 East Cour~ Avenue
Jeffersonville, IN 47130
(812) 285-6422
(8t 2) 285-6426
pwilde r@cityo fjeff, net
Suzy Bass/Deputy Clerk
City of Jc=~ersonville
501 East Cour~ Avenue
Jeffersonville, IN 47130
(812) 285-6423
(812) 285-6426
sbass@cityofjeff, net
Leslie Merkley/City Attorney
City of Jeffersonville
501 East Court Avenue, Room 410
Jeffersonville, IN 47130
(812) 285~491
(812) 285-6468
Imerkley@cityo~eff. net
Name/T/fie:
Company:
Address:
Telephone:
Name/Title:
Company:
Address:
Telephone:
Fax Number:
Email:
Updated Apdl 1, 2004 3 General Information
City of Jeffersonvi[le
Effective: Apdl I, 2004
GENERAL INFORMATION:
21. The following person(s) are authorized to receive protected health information (PHI) (include information
for infernal contacts, i.e. management, administrative, financial; external contacts,i.e. Flex Administrator,
Cobra vendor or AgentJBrokerlConsultaot, if applicable). CONTINUED
Name/Title:
Company:
Address:
Telephone:
Fax Number:
Klm Calabro/Directer of HR
City of Jeffersonville
501 East Court Avenue, Room 407
Jeffersonville, IN 47130
(812) 285-6405
(812) 285~6490
kcalabro@cityot~eff, net
Rob Waiz/Mayor
City of Jeffersonville
501 East Court Avenue
Jeffemonville, IN 47130
(812) 285-6400
(812) 285-6403
mayor@c[tyof~eff, net
Name/Title:
Company:
Address:
Telephone:
Fax Number:
NOTE: PHI information will be provided only to the individuals idenfified above, but will not go into effect
until the signed Plan Management Agreement is returned to HumanaDental.
22. The following individual is the plan representative for claim appeals.
Name/Title: Leslie Merkley/City Attorney
Company: City of Je[fersonville
Address: 501 East Court Avenue
Jeffersonville, IN 47130
Telephone: (812) 285~491
Fax Number: (812) 285-6488
Email: Ime rkley@cityot]eff, net
Flexible Spending Administration:
1. Does Plan have a Flex Administrator:
NO
X Yes
Administrator Name: AFLAC
Address: 1505 Allison Lane
Jeffersonvi~le, IN 47130
Telephone:
Contact Name: Christina Johnson
2. What is the flex plan enrollment period:
Updated April I, 2004 4 General Information
City of Jeffersonville
Effective: Aprfi 1, 2004
CLAIMS COST MANAGEMENT
The following provisions are included within the group's administrative fees. However, if legal fees are required to
recover the greup's money, the legal foes will be the group's respansibility.
1. Check all that apply:
No recovery provision
X Limitation and Exclusion (L&E) - Provides for tbe appreprlate first party insurance
insurance carrier to pay dental claims first, such as an auto carders medical payment coverage
The other carrier would be primary over the dental plan. NO payment will be made until that coverage
is exhausted; Once the auto cardeds medical payment is exhausted, the Plan will then begin to pay the eligible
dentar claims. The primary liability is transforred to the other carder.
X Reimbursement/Subrogafion - Subrogation allows the Plan to "stand in the shoes of the covered
person and collect money from the responsible party." Once the Plan pays, we have a contractual
dg;~ to request money back f~om the respansible party or their insurance carder,
Reimbursement allows the Plan, by a contractual right, to recover the money the Plan paid on the behalf of the
of the covered parson, when benefits are paid and the cove~l person recovers monetary damages
from the responsible party. This can be either by a settlement, judgement, or other manner·
X Business Exception- Do not enforce L&E or pumue recovery for injuries with
no liability occurred at a friend's, relative's, neighbor's, or church's property where other primary
coverage is available (e.g., medical payments expanse coverage)>
X Reimbursement without pro-rata - Priority reimbursement means if an injured person is not made
whcte (fuliy compensated for the loss from the settlement money), reimbursement will be made to the Plan
2. up to 100% of any expanses paid regardless of the amount of the settlement or the extent of the injuries
incurred.
made whole (fully compensated for their loss from the settlement money), the account agrees to "share"
Are them any existing third party liability files? X No
If yes, will these files be transferred to HumanaDental for handling?
No Yes, approximate number of files:
Workers' Compensation Carrier Information:
Name: Downey - IPEP
Address: P.O. Box 690, Kokomo. IN 46903
4. Telephone: 800-382-8837
Contact Name: Louise Sparks
Yes
If a covered person or their employer could have purchased Workers' Compensation coverage but chose not to,
should HumanaDental process those claims subject to the terms and provisions of the dental plan? This refers to, but
not limited to, self-employed people, fanners and business owners.
X NO Yes
Updated April I, 2004 I General Information
City of Jeffersonville
Effective: April 1, 2004
SUMMARY PLAN DESCRIPTION DESIGN AND MAILING INFORMATION
1. Who will do printing?
HumanaDental Own printing service
Quantity
X Undetermined, provide estimated quote. Quantity: 275
Include estimated cost for shipping to group
2. How many different summary plan descriptions are needed"
X Dental
Combined, specify:
3. Size of summary plan description:
3a. Summary plan description type:
X Booklets (Stitched)
Binders (3-Hole Drilled)
3b. Are binder, tabs or dividers needed?
X NO
Yes
If binder, tabs or dividers are needed, the Contract Analyst will contact you directly regarding the type/style.
4. Should summary plan description be printed according to
Hourly
Saleded
By Location
X Combined, specify: t book for all
5. Should employer's logo be included on the front cover of the summary plan description?
X No
Yes. provide camera ready logo (color separated if applicable) and PMS colors, if applicable.
6. Should the agerd/brokerlconsultent name appear on the back cover?.
X ,No
Yes, specify or provide sample
7. Contact pemon to work with for booklet drafts and other documents?
Name: Klm Calabro
Email: kcalabm@cifyof]eff, net
Updated April t, 2004 I General Information
Effective
ENROLLMENT INFORMATION
1. DO these eligibility p~ovisions apply to all self-f~nded lines of coverage?
Medical
X Dental
Short Ten'n Disability
Prescription Drug
Other, specify:
2. Does the Plan voluntarily apply HIPAA provisions to non-medical lines of coverage?
X Yes
No, specify:
3. Open Enrollment:
No
X Yes
A. Does pre-x apply? No Yes NA
B. How many times a year is open enrollment allowed? Once per year
C. When is the open enrollment period? 03/01 to 03/31, eff~t[ve 04/01
D. Can someone who previously declined coverage appiy during open enrollment period?
NO X Yes
E. Does open enrollment apply to a~l lines of coverage? No X Yes
4. Dual Choice
X
No
Yes
Is the other choice an HMO?
No Yes
When can the other choiCe be selected?
Does pre-x apply? Yes
No
5. How will Enrollment be provided?
Via the Web
EDI (Electronic)
Paper
Scannable
6. How often will enrollment changes be provided?
X Upon occurrence
Weekly
Bi-weekly
Monthly
Other, specify:
7. If enrollment will be provided electronically, has electronic submission been approved by the
enrollment unit? NA
No
Yes
Group Name
Effective
ENROLLMENT INFORMATION
Employee Eligibility
1. Eligible employees include:
X Active Employees
X Redrees (must meet all eligibiffiy requirements as specified by state or city ordinance in order to be considered eligible)
X Survivors
Seasonal
Part-time: specify
X Other; specify elected / appointed officials
Eligibility requirements: 30 Hours per week
Weeks per year
X Other; specify
1000 hr / year in foil-time covered position / elected and appointed officials
3. Eligibility period:
X None
30 days calendar days worked days
60 days calendar days worked days
90 days calendar days worked days
Other; specify
4, Effective date:
X Immediate
1 st of month after eligibility period
Other; specify
NA
A, What is the pre-existing waiting period for a timely applicant?
Months pdor to employment date
Months maximum deny following the employment date (not to exceed 12 months)
B. Are ali lines of coverage affected by the pre-existing condition waiting period(s)?
Yes
NO; specify
2 Enrollment
Group Name
Effective
ENROLLMENT INFORMATION
NOTE: If Plan has dental coverage, please refer to that section!:
6. Does the Plan have a late applicant provision? (If Plan has dental coverage, please refer to that section
for dental rata applicant information.)
Yes, if application is submitted more than days after the eligibility date
A. When is a late applicant effective?
Immediately following receipt of a completed enrollment form
1 st of month following receipt of a completed enrollment form
Other; specify
B. Does pre-x apply to a late applicant?
No
Yes
Is the pre-existing waiting period the same for a late applicant as for a timely applicant?
Yes
No
If No, what is the pre-existing waiting period for a late applicant?
Months prior to enrollment date
Mths maximum deny following the employment data (net to exceed 18 months)
X No, how should late applicants be handled?
X
Not eligible for coverage
Same as a fimeiY applicant
Coverage delayed until nex~ open enrollment pehod
D. Does pre-x apply to late applicant?
No
Yes
What is the pre-existing waiting period?
Months prior to enrollmen~ dete
Mths maximum deny following the employment date (not to exceed t 8 months)
7. Does the Plan have an "activety at work" provision?
X No
Yes, specify;
8. Termination date:
X Immediate, last day worked
End of the month
Other; specify
3 Enrollment
Effective
ENROLLMENT INFORMATION
NOTE: The following apply to absences from work not subject to FMLA guidelines.
9. Special provisions for continuing coverage when not in active status:
Layoff, coverage terminates: immediate
X End of Month
After Days
After Months
If COBRA elected, COBRA time pe~od is measured:
From daft of layoff
X Immediately following end of coverage pedod
Other
Medical Leave of Absence (other than FMLA) coverage terminates:
Immediate
X End of Month
After Days
After Months
ff COBRA elected, COBRA time pedod is measured:
From date of Medical Leave of Absence
X Immediately following end of coverage period
Other
Total Disability, coverage ftrminates: Immediate
X End of Month
After Days
After Months
If COBRA elected, COBRA time period is measured:
From date of Total Disability
X Immediately ftllowing end of coverage period
Other
Immediate
X End of Month
After Days
After Months
if COBRA elected, COBRA time period is measured:
X Immediately following end of coverage period
Other
Approved Military Leave of Absence, coverage terminates:
immediate
End of Month
After Days
X After 18 Months, or for the period of milita~, service, whichever is shorter
If COBRA elected, COBRA time period is measured:
From date of Milita~/Leave of Absence
X Immediately following end of coverage period
Other
4 Enrollment
Group Name
Effective
ENROLLMENT INFORMATION
10. Reinstatement provisions:
A. Following Layoff:
Is the eligibility pedod waived? NA
Yes No
Effective date?
X immediate First of Month
Does pre-existing apply? NA
Yes No
Otl~er, specify;
B. Following Medlcai Leave of Absence:
Is the eligibility period waived? NA
Yes No
Effective date?
X Immediate First of Month
Does pre-existing apply? NA
Yes No
Other, specify;
Following return from Total Disability:
Is the eligibility period waived? NA
yes No
Effective date?
X ~mmediate First of Month
Does pre-existing apply? NA
Yes No
Other, spec[fy;
Followlng return from Non-Medical Leave of Absence:
Is the eligibility period waived? NA
yes NO
Effective date?
X Immediate First of Month
Does pre-existing apply? NA
Yes No
Other, specif~;
5 Enrollment
Group Name
Effective
ENROLLMENT INFORMATION
10. Reinstatement p~ovisions: (continued)
E. Following return from Military Leave of Absence:
Is the eligibility pedod waived? NA
Yes No
Effective date?
X Immediate First of Month
Does pre-existing apply? NA
Yes No
Other, specify;
Following rrdum from par~-time Status:
Is the eligibility peded waived? NA
Yes No
Effective date?
X Immediate First of Month
Does pm-existing apply? NA
Yes No
Other, specify;
11. Does the Plan beve an extenrdon of bene~te provision?
X No
Yes,
(If a member is totally disabled on the date coverage terms, the Plan continues to provide benefits:)
1. Uctil member is no longer disabled;
2. Until member reaches Plan maximum benef'd;
3. Up to a maximum of 12 months; for DISABLING CONDITION ONLY;
Does the prior Carder have an extension of benefits provision?
No
Yes, who is our contact rd the pper Carder?
Name:
Company:
Phone:
Fax:
12. Special enrollment applies to dental coverage as a result of HIPAA:
Effective drde of coverage as a result of entering the Plan through special enrollment
Immediate
1 st of month following receipt of the completed enrollment term
Pre-existing will be: NA
Waived
Applied to a covered person entering the Plan as a result of special enrollment
6 Enrollment
Group Name
Effective
ENROLLMENT INFORMATION
Dependent Eligibility
1. Dependents include:
X Spouse
X Natural Blood-Related Children
X Adopted Children
Step Children
X Legal guardianship
Grandchildren, until dependent parent reaches age
Domestic Parmers
2. Dependent child eligibility requirements:
X Must qualify under IRS guidelines.
Must be claimed on taxes
Other; specify
Covered to:
Age: 23 and to age: 25 if Full Time Studer~
3. Newborn requiren3ents:
A. When a change in the employee's level of coverage is not required:
May enroll by telephone call from employer
X Must submit enrollment form to add
Other; specify
When a change in the employee's level of coverage is required:
X Must submit enrollment form within
Other; specify
3t days
3. Newbom requirements: (continued)
Dependent (other than newboms) enrollment:
When a change in the employee's level of coverage is not required:
May enroll by telephone call from employer
Must submit enrollment form to add
Other; specify
When a change in the employee's level of coverege is required:
X Must submit enrollment form within
Other; specify
31 days
4. Dependent tem3ination;
X Date no longer eligible
End of month no longer eligible
Other; specify
7 Enrollment
Group Name
Effective
ENROLLMENT INFORMATION
Retiree Provisions
1. Does the Plan have a retiree class?
No
X Yes
2. Does the Plan allow early retirees?
No
Yes
A. Early retiree§ eligible as per state law / statue,
B. Early retiree's are eligible for;
Medical X Dental
Other; specify
C. Do early retiree's keep the same benefit Plan as when they were in active status?
Yes
No; specify
3. EaHy retiree coverage age limits, if any:
Medical age limit
65 Dental age limit; if spouse is under age 65, spouse may continue as a single plan to to age 65.
Other, specify:
4. Does the Plan allow retirees over age 657
X NO
Yes
A. Retirees over age 65 are eligible for:
Medical Dental
Other; spec[fy
B. Do retirees over age 65 keep the same benefit Plan as when they were in active status?
Yes
No; specify
5. Retiree age limits, if any:
Medical age limit:
Dental age limit;
NA
6. If retiree has one dependent, are retiree and dependent each assigned single coverage at
retiremeet?
Yes
X No
7. Are there any provisions for adding dependents acquired through marriage after retirement~
X May be added by timely enrollment.
Are not eligible to be covered.
Other, spec[fy;
8 Enrollment
Group Name
Effective
ENROLLMENT INFORMATION
Survivorship Provisions:
1. Survivorship coverage is: X COBRA
X Other; specify where specified by state statute or city ordinance, coverage terminates at age 65.
2. If other than COBRA: Per state statute / cr~y ordinance
Medical age limit:
Dectal age limit:
X Coverage terminates, doex
4. Dependents acquired through remarriage:
X Are not eligible to be covered, does not apply to COBRA
May be added by timely er~rollment
Other; specify
9 Enrollment
City of Jeffersonville
Effective: Apdl 1, 2004
DENTAL GENERAL BENEFIT INFORMATION:
Passive PPO:
Deductible:
$50.00
$150.00
X
$ Individual
$ Aggregate Family Dollars
Separate Individual Deductibles Per Family
Calendar Year
Plan Year (date)
2. Deductible applies to:
Preventative Services
X Basic Restorative Services
X Major Restorative Services
X Prosthodontics
Orthodontics
3. Does the group have last throe month carry-over deductible credit?.
X Ne
Yes
4. What is the individual annual maximum?
$1,500.00
5. is the individual annual maximum waived on?
Preventative Services
Basic Restorative Services
Major Restorative Services
Pmsthodontics
X Orthodontics
6. At what percentage are the following services covered?
100% Preventative Services
80% Basic Restorative Services
50% Major Restorative Services
50% Prasthodontics
50% Orthodontics
7. Proof of loss period:
12 months
X 15 months
Other, specify;
Updated:4/2/2004 1 Dental Benefits/General Info
City of Jeffersonville
Effective: Apdl 1,2004
DENTAL GENERAL BENEFIT INFORMATION:
8. Maximum allowable schedules: (HIAA)
X 90th percentile (0390)
85th percentile (0385)
80th percentile (0380)
75th percentile (0375)
9. Maximum allowable variance dollar amount (Flex amount):
X $0.00
Other, sped~y;
t0. Maximum allowable variance percentage:
X 0%
Other, specify;
11~ Do we allow the greater or lesser or both the dollar amount and the percentage?
X N/A Greater Lesser
12. Will the Plan pay any applicable tax in states required for providers of service (i.e- Minnesota)?
No X Yes
13. Is them an extension of benefits?
X No Yes, specify what services it applies to:
Root Canals Crowns
Dentures Bridges
Orthodontics Other:
60 Days
Other, specify;
Inlays/Onlays
Partial Dentures
'14. Pm-treatment estimates:
X Recommended, $300
Recommended, specify
Required, specify:
Not applicable
Pre-treatment estimates am valid for:
30 days X
90 days
180 days
Other, specify:
15. Is there an alternate services provision?
No X Yes
Updated:4/2/2004 2 Dental Benefits/Generat Info
City of Jeffersonville
Effective: April 1, 2004
DENTAL GENERAL BENEFIT INFORMATION:
16. Coordination of Benefits Provision:
A, 100%
X Normal Liability
If 100% is selected, should a reserve be created?
NO Yes
B. X Birthday Rule Male/Female
C. Are services that are covered under both medical and dental to be coordinated with?
No X Yes
X Medical Primary Dental Primary
17. Late applicant provision applies to: NIA
Basic Restorative 12 Months Other
Major Restorative 12 Months Other
Prosthodontics 12 Months Other
Orthodontics 12 Months Other
Preventative 12 Months Other
Other, Time [imitation
Is the late applicant provision waived if due to an accident?
No Yes
t8. Are replacement appliances covered if lost, broken or stolen?
X NO Yes
Are duplicate appliances covered?
X No
Yes
19. Are appliances or restorations covered for: A. Increasing vertical dimension
B. Restoring occlusion
C. Replacing tooth structure lost by attrition
D. Correction of congenital development ma[formation
X No
X No
X No
X No
Yes
Yes
Yes
Yes
20. How are study models covered?
X Integral
Combined with service rendered
Separate, payable as:
Preventative
Basic Restorative
Major Restorative
Prosthodontics
Other ~ TMJ
%
%
%
%
%
Updated:4/2/2004 3 Dental Benefits/General Info
City of Jeffersonville
Effective: Apdl 1,2004
DENTAL GENERAL BENEFIT INFORMATION:
21. Is there a replacement provision?
X Major Restorative X Pmsthodontics
Frequency limit:
X I per 5 years and unserviceable Other, specify;
22. Are congenitally missing teeth covered?
No X Yes
23. Is there a "missing tooth" clause?
X Yes
X Not covered if extracted prior to the effective date:
No
Other, specify;
24. Are services for cosmetic purposes covered?
X No Yes
Updated:4~2~2004 4 Dental Benefits/General Info
City of Jeffersonville
Effective: April 1, 2004
DENTAL GENERAL BENEFIT INFORMATION:
Passive PPO:
1. Deductible:
$50.00
$150.00
X
$ Individual
$ Aggregate Family Dollars
Separate Individual Deductibles Per Family
Calendar Year
Plan Year (date)
2. Deductible applies to:
Preventative Services
X Basic Restorative Services
X Major Restorative Services
X Prosthodontice
Orthodontics
3. Does the group have last three month carry-over deductible credit?
X No
Yes
4. What is the individual annual maximum?
$1,500.00
Is the individual annual maximum waived on?
Preventative Services
Basic Restorative Services
Major Restorative Services
Presthodontics
X Odhodontics
At what percentage are the following services covered?
100% Preventative Services
80% Basic Restorative Services
50% Major Restorative Services
50% Presthodontics
50% Orthodontics
7. Proof of loss period:
12 months
X 15 months
Other, speciflJ;
Updated:4/2/2004 I Dental Benefits/General Info
City of Jeff~rsonville
Effective: Apdl 1, 2004
DENTAL GENERAL BENEFIT INFORMATION:
8. Maximum allowable schedules: (HIAA)
X 90th percentile (0390)
85th percantiie (0385)
80th percentile (0380)
75th percentile (0375)
9. Maximum allowable variance dollar amount (Flex amount):
X $0.00
Other, specify;
t0. Maximum allowable variance percentage:
X 0%
Other, specity;
tt. Do we allow the greater or lesser or both the dollar amount and the parcentage?
X N/A Greater Lesser
12. Will the Plan pay any applicable tax in states required for providers of service (i.e.. Minnesota)?
No X Yes
13. Is there an extension of benefits?
X No Yes, specity what services it applies to:
Root Canars Crowns
Dentures Bridges
Or[hodonfics Other:
60 Days
Other, specify;
Inlays/Onlays
Partial Dentures
t4. Pre-treatment eatimates:
X Recommended, $300
Recommended, specify $
Required, specify:
Not applicable
Pre-treatment estimates are valid for:
30 days X
90 days
180 days
Other, specity:
'15. Is there an aitsrnate services provision?
No X Yes
Updated:4/2/2004 2 Dental Benefits/General Info
City of Jeffersonville
Effective: April 1,2004
DENTAL GENERAL BENEFIT INFORMATION:
16. Coordination of Benefits Provision:
A. 100%
X Normal Liability
if 100% is setected, should a reserve be created?
No Yes
B. X Bi[thday Rule
Male/Female
Are services that are covered under both medical and dental to be coordinated with?
No X Yes
X Medical Primary Dental Primary
~17, Late applicant provision applies to: NIA
Basic Restorative 12 Months Other
Major Restorative 12 Months Other
Pmsthodontice 12 Months Other
Otthodontics 12 Months Other
preventative 12 Months Other
Other, Time limitation
Is the late applicant provision waived if due to an accident?
No Yes
'18. Are replacement appliances cOvered if lost, broken or stolen?
X No Yes
Are duplicate appliances covered?
X No
Yes
'19. Are appliances or restorations covered for: A. Increasing vertical dimension
B. Restoring occlusion
C. Replacing tooth structure lost by attrition
D. Correddon of congenital development malformation
X No
X No
X No
X No
Yes
Yes
Yes
Yes
20. How are study models covered?
X Integral
Combined with service rendered
Separate, payable as:
Preventative
Basic Restorative
Major Restorative
presthodontics
Other - TMJ
%
%
%
%
%
Updated:4/2/2004 3 Dental Benefits/General Info
City of Jeffersonville
Effective: April 1. 2004
DENTAL GENERAL BENEFIT INFORMATION:
21. Is there a replacement provision?
X Major Restorative X Pmsthodontics
Frequency limit:
X I per 5 years and unserviceable Other, specify;
22. Are congenitally missing teeth covered?
No X Yes
23. Is there a "missing tooth" clause?
X Yes
X Not covered ~f extracted pdor to the effective date:
No
Other, specify;
24. Are services for cosmetic purposes covered?
X No Yes
Updated:4/2/2004 4 Dental Benefits/General Info
NEW CASE DOCUMENT
CITY OF JEFFERSONVlLLE
Effective Date:
Apdl 1, 2004
Group Number(s)
3955887-Active
3955888-COBRA
3955889-Retiree/Survivors
Product Number(s)
03/4667