Other Helpful Information

Continuation Coverage (COBRA)

If you or one of your dependents become ineligible for employer paid dental coverage, you may be eligible to continue your coverage under the federal COBRA program. Contact your agency for more details.

Termination of Coverage

Your Delta Dental coverage may be automatically terminated:

• When your employer or organization advises Delta Dental to terminate your coverage.
  
• On the last day of the month for which your employer or organization has failed to pay Delta Dental, or for any other reason stated in this Summary Plan Description.

In no event will eligibility for any person covered under this program continue beyond the date your employer advises Delta Dental or organization to terminate eligibility, except to the extent that COBRA is applicable.

Change of Status

You must notify Delta Dental, through your employer or organization, of any event causing a change in the status of an Eligible Dependent. Events that can affect the status of an Eligible Dependent include, but are not limited to, marriage, birth, death, divorce and entrance into military service.

Assignment

Services and/or benefit payments to Subscribers and Eligible Dependents are for the personal benefit of those people and cannot be transferred or assigned.

Subrogation

If Delta Dental pays a claim for which another person or company is liable, Delta Dental has the right to recover its payment from the other person or company.

Obtaining and Releasing Information

While you are covered by Delta Dental, you agree to provide Delta Dental with any information it needs to process your claims and administer your benefits. This includes allowing Delta Dental to have access to your dental records.

Dentist-Patient Relationship

You and your Eligible Dependents have the freedom to choose any Dentist. Each Dentist maintains the dentist-patient relationship with the patient and is solely responsible to the patient for dental advice and treatment and any resulting liability.

Loss of Eligibility During Treatment

If you or your Eligible Dependent lose eligibility while receiving dental treatment, only covered services received while you or your Eligible Dependent were covered under the Plan will be payable.

Certain procedures begun before the loss of eligibility may be covered if the services were completed within a 60-day period measured from the date of termination. In those cases, Delta Dental evaluates those services in progress to determine what portion may be paid by Delta Dental. The balance of the total fee is your responsibility.

Late Claims Submission

Delta Dental will not honor and no payment will be made for services if a claim for those services has not been received by Delta Dental within one year following the year in which the services were completed.

Governing Law

The group contract and/or Certificate will be governed by and interpreted under the laws of the State of Ohio.

Your Rights In The Event Of Insolvency

Ohio law requires Delta Dental to make the following statements:

As a licensed health-insuring corporation (HIC) Delta Dental is not a member of a Guarantee Fund. In the event of Delta Dental's insolvency, you are protected only to the extent that the provision in the contracts between Delta Dental and its Dentists in which providers agree not to bill members, applies to the dental services you receive.

In addition, in the event of Delta Dental's discontinuance of operations, Dentists are required to provide covered dental services that are medically necessary to complete previously initiated treatment, but this is limited to the thirty (30) day period following discontinuance of operations.

Participating Dentists are not required to continue to provide covered dental services past the occurrence of the earliest of the following events.

1. The end of the thirty (30) day period following the filing of the liquidation order per Ohio law;
2. The end of the member's contract year;
3. The date the member obtains equivalent coverage;
4. The end of the member's period of coverage for a contractual prepayment of premium;
5. Legal transfer of Delta Dental's obligations.

In the event of Delta Dental becoming insolvent, you may be financially responsible for dental services rendered by a provider or facility that is not under contract with Delta Dental whether or not Delta Dental authorized the use of the provider or health care facility.

In addition, in the event of Delta Dental's discontinuance of operations, as required by Ohio law, Delta Dental is required to submit to the Ohio Superintendent, documentation of an arrangement to provide medically necessary health care services to members until the expiration of the member's contract year. As required by Ohio law, this arrangement to provide medically necessary health care services may be made by using any one, or any combination of the following methods.

1. The maintenance of insolvency coverage;
2. A provision in participating providers' contracts with Delta Dental, provided such provision is not solely relied upon for more than thirty (30) days;
3. In agreement with any other health insuring corporations or insurers, providing members with automatic conversion rights upon the discontinuance of Delta Dental's operations; or
4. Such other methods as approved by the Superintendent of Insurance.

In the event any of the foregoing situations applies to you, please contact Delta Dental at 1-800-524-0149.

Insurance fraud significantly increases the cost of health care. If you are aware of any false information submitted to Delta Dental, you could help lower these costs by calling the Toll-Free Hotline. Only ANTI-FRAUD calls can be accepted on this line.

ANTI-FRAUD TOLL-FREE HOTLINE:

1-800-524-0147

The following statement is required for this document by Ohio law:

Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.