Any and all rights or benefits accruing to any Covered Individual under these Plans shall be subject to all terms and conditions of these Plans. The adoption and maintenance of these Plans shall not constitute a contract between The Pennsylvania State University and any Employee or be a consideration for, or an inducement or condition of, employment of any Employee. Neither participation nor anything contained in these Plans shall give any Employee the right to be retained in the employ of the University, nor shall it interfere with the right of the University to discharge any Employee at any time.
You will be eligible to be enrolled in these Plans if you are actively employed in the regular, full-time service of the University. Your dependents will be eligible for coverage on the day your coverage begins, or whenever they become eligible dependents. A dependent spouse eligible for coverage prior to age sixty-four but not enrolled prior to age sixty-four may not, thereafter, be eligible for coverage purposes.
Your coverage becomes effective on your date of hire, provided you have signed the necessary enrollment forms no later than thirty-one days from your date of employment. Employees and dependents may enroll for coverage in Dental only; Vision only; or both.
No dependent coverage can be elected unless the employee is covered. An Employee may cover his or her dependent spouse even if the dependent spouse is also an employee of the University. However, no one is eligible to be covered as a dependent spouse under a University-sponsored plan if already covered as an employee under a University-sponsored plan, or vice versa.
Children can be covered under only one parent's University-sponsored plan if both parents are employed by the University and are eligible for benefits.
It is important that you give prompt notice to the Employee Benefits Division of any change in your dependent status which may change your contribution rate.
If you are enrolled for personal coverage only and thereafter marry or otherwise acquire a dependent, dependent coverage will become effective on the date you acquire the dependent, provided you enroll for dependents' coverage not later than thirty-one days following the date you acquire them.
The effective date of coverage for an adopted child is the date of the Intent to Adopt form if the form is received by the Employee Benefits Division within thirty-one days of the date the form was executed. For a newborn adopted child, coverage is effective on the child's date of birth provided the Intent to Adopt form is executed and received by the Employee Benefits Division within thirty-one days of such date.
Each enrolled Employee or covered dependent shall file with the University such pertinent information concerning the Covered Individual as the University or the Plan administrator may specify, including proof or continued proof of eligibility, and in such manner and form as the University or the Plan administrator may specify or provide; and such person shall not have rights or be entitled to any benefits or further benefits hereunder unless such information is filed by the Covered Individual or on the Covered Individual's behalf.
Coverage can be terminated at any time by submitting a Request for Change of Healthcare, Dental, and Vision Coverage form to the Employee Benefits Division. Coverage will terminate on the date indicated on the form if the form is received in the Employee Benefits Division within 31 days of that date. Otherwise, coverage will terminate on the date the form is received in the Employee Benefits Division. Refunds for contributions for coverage will not be made unless the overpayment resulted from a University error.
Eligible dependents are your spouse (unless legally separated) and dependent children. Dependent children are covered until their nineteenth birthday or until reaching their twenty-fourth birthday if they are full-time students (including a student who is on leave of absence granted by the school for a period of not more than one term or semester). Dependent children are defined as unmarried children, adopted children, or stepchildren until their nineteenth birthday or until reaching their twenty-fourth birthday if they are full-time students, and physically handicapped or mentally retarded children who are incapable of self-sustaining employment, regardless of age, provided they are covered prior to the maximum age otherwise applicable.
If a dependent child is mentally retarded or physically handicapped so as to be incapable of earning a living when coverage would terminate due to age, coverage may be continued. Contact the Employee Benefits Division within 31 days before coverage terminates for the appropriate form to continue coverage.
A disability due to accidental bodily injuries arising out of and in the course of the employee's employment with any employer or due to disease with respect to which benefits are payable under any Workers' Compensation, occupational disease, or similar law.
The charge, fee or expense usually made by the provider not to exceed a usual and customary charge in a defined region.
Dental and Vision (for nonparticipating providers) forms used to submit claims may be obtained from the Employee Benefits Division at University Park and from the business or personnel office at locations other than University Park. Assistance is always available from the Employee Benefits staff.
Payment for Dental and Vision claims may be made directly to the provider of service if the employee completes the statement on the claim form. Otherwise, payment will be made to the employee. Dental and Vision claims should be mailed to the addresses shown on the claim forms. Network providers will submit the claims directly to the insurance carrier.
Failure to submit claims within one year of the date of service will result in your claims being denied.
If the University shall find that any person to whom any benefits are payable under these Plans is unable to care for their personal affairs, is a minor or has died, then any payment due a Covered Individual or the estate (unless a prior claim has been made by a duly appointed legal representative) may be paid to the spouse, a child, a relative, an institution maintaining or having custody of such person otherwise entitled to payment; or the University may, in its discretion, hold such payment until a legal representative is appointed. Any such payment shall be a complete discharge of the liabilities of this Plan.
The plans contain a nonprofit provision coordinating it with other similar plans under which an individual is covered so that the total benefits available will not exceed 100% of the allowable expenses.
An "allowable expense" is any necessary, reasonable and customary expense covered, at least in part, by one of the plans of the same type.
"Plans" means these types of dental and vision care benefits:
(a) coverage (other than Medicare or Medicaid) under a governmental program or provided or required by statute, including no-fault coverage to the extent required in policies or contracts by a motor vehicle insurance statute or similar legislation, and (b) group insurance or other coverage for a group of individuals, including student coverage obtained through an educational institution.
When a claim is made, the primary plan pays its benefits without regard to any other plans. The secondary plans adjust their benefits so that the total benefits available will not exceed the allowable expenses. No plan pays more than it would without the coordination provision.
A plan without a coordinating provision similar to ours is always the primary plan. If all plans have such a provision: (1) the plan covering the patient directly, rather than as an employee's dependent, is primary and the other is secondary; (2) if a child is covered under both parent's plans, the plan of the parent whose birthday falls earlier in the year is the primary plan. But, if both parents have the same birthday, the plan which covered the parent longer is the primary plan. However, if the other plan does not have this rule, but instead has a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule of the other plan will determine the order of benefits.
When the parents are separated or divorced, their plans pay in this order: (a) if a court decree has established financial responsibility for the child's health care expenses, the plan of the parent with this responsibility; (b) the plan of the parent with custody of the child; (c) the plan of the stepparent married to the parent with custody of the child; (d) the plan of the parent not having custody of the child. (3) If neither (1) nor (2) applies, the plan covering the patient longest is primary, except as follows: (i) the benefits of a Plan which covers the person as an employee other than as a retired employee, or a dependent of such person, shall be determined before the benefits of a Plan which covers the person as a retired employee, or a dependent of such person; and (ii) if either Plan does not have a provision regarding retired employees and, as a result, each Plan determines its benefits after the other, then the provisions of (i) above shall not apply. When ours is the secondary plan and its payment is reduced because of the primary plan's benefits, a record is kept of the reduction. This amount will be used to increase our plan's payments on the patient's later claims in the same calendar year to the extent there are allowable expenses that would not otherwise be fully paid by our plan and the others.
All coverage will be continued during the period for which you continue to receive your regular wages or salary from the University. Thereafter, coverage may be continued during the period for which you have been granted a leave of absence without pay for illness or injury. At the conclusion of any such leave of absence, all coverage will be terminated, except under the following conditions:
If your leave of absence is without pay due to sickness or maternity, formal study, or leave in lieu of temporary layoff, you will be billed for your share of the monthly cost. For all other leaves of absence, you may continue coverage by paying the full cost (University's contribution, plus employee's contribution). If medical coverage is declined for the period of the leave, you will be required to wait until the University's annual open enrollment period to reenroll. Medical benefits will be effective on January 1 of the subsequent year. If dental and/or vision are declined and enrollment is requested at a later date, late enrollment waiting periods and benefits limits will apply.
You may continue your coverage for a period of up to 120 days by paying the regular rates if your termination of employment is other than the end of a fixed-term appointment and results from a reduction in force. Benefits may be continued beyond 120 days under the provisions of COBRA up to a maximum of 18 months. You should contact the Employee Benefits Division for details.
It is not possible for an employee granted a military leave of absence to continue personal coverage; however, dependent coverage may be continued by notifying the Employee Benefits Division prior to the effective date of military leave. When you return from military service, you may become covered again when you resume fulltime employment.
If your employment is terminated for any reason other than outlined above, when you are no longer eligible or when the plan terminates, all coverage under the program ceases at the end of the pay period in which your termination occurs.
If you cease active work, benefits may be continued under provisions of COBRA up to a maximum of 18 months.
Dependent children who reach age 19, or cease to be a full-time student prior to age 24, or reach age 24 while still a full-time student may continue coverage under provisions of COBRA to a maximum of 36 months. The Employee Benefits Division must be notified within 60 days if coverage is to be continued.
Coverage for dependents may be continued under provisions of COBRA to a maximum of 36 months following the divorce of any employee. The Employee Benefits Division must be notified within 60 days of the divorce if coverage is to be continued.
The Plans will not pay for covered expenses for injuries received as a result of an accident for which a third party is liable. However, if the third party's liability is less than the amount that would otherwise by paid by these Plans, the difference will be paid by these Plans.
If you or your covered dependents incur expenses for injuries received in an accident for which a third party may be liable, you will be asked to sign an agreement stating that you will refund any amount paid by these Plans for which a third party is later determined to be liable.
If a Covered Individual has been paid benefits under these Plans which are in excess of the benefits that should have been paid, or which should not (under the provisions of the Plans) have been paid, the University or Plan Administrator may cause the deduction of the amount of such excess or improper payment from any subsequent benefits payable to such Covered Individual or other present or future amounts payable to such person, or recover such amount by any other appropriate method that the University, in its sole discretion, shall determine. Each Covered Individual hereby authorizes the deduction of such excess payment from such benefits or other present or future compensation payments.
No term, condition or provision of these Plans shall be deemed to have been waived, and there shall be no estoppel against the enforcement of any provision of these Plans, except by written instrument of the party charged with such waiver or estoppel. No such written waiver shall be deemed a continuing waiver unless specifically stated therein, and each such waiver shall operate only as to the specific term of condition waived and shall not constitute a waiver of such term or condition for the future or as to any act other than that specifically waived.
If the University is unable to ascertain the whereabouts of any Covered Individual to whom benefits are payable under these Plans, and if, after one year from the date such payment is due, a notice of such payment due is mailed to the last known address of such person as shown on the records of the University and within three (3) months after such mailing, such person has not filed with the Plan Administrator written claim, therefore, the University may direct that such payment be canceled and forfeited and, upon such cancellation of these Plans shall have no further liability therefore.
For the purpose of determining the applicability of implementing the terms of these benefits, the University and/or Plan Administrators may, without the consent of or notice to any person, release or obtain any information necessary to determine acceptability of any applicant for participation in these Plans. In so acting, the University and/or Plan Administrator shall be free from any liability that may arise with regard to such action. Any Covered Individual claiming benefits under these Plans shall furnish to the University and/or Plan Administrator such information as may be necessary to implement this provision.
These Plans are not in lieu of, and does not affect, any requirement for coverage by Workers' Compensation Insurance.
In the event of any misstatement of any fact(s) affecting coverage under these Plans, the true facts will be used to determine the proper coverage. Coverage means eligibility as well as the amount of any benefits thereunder.
The University has established the Plans described herein with the intention of maintaining them for an indefinite period. However, the University reserves the right at any time to amend or terminate a Plan, or any part thereof, including by way of illustration and not limitation:
The right to amend or terminate a Plan is vested in the Assistant Vice President for Human Resources as delegated by the President of the University.
Except as otherwise provided in a Plan, the right to amend or terminate the Plan shall not in any way affect the right of a participant or eligible dependent to claim benefits, or diminish or eliminate any claim for benefits, with respect to expenses incurred for services rendered to a participant or eligible dependent prior to termination or amendment of a Plan.
A Plan is not a contract and the University does not guarantee and makes no promise to offer a specific level of benefits under the Plan in the future. The right to future benefits under any Plan will never vest.
Eligibility of a faculty or staff member to take benefits into retirement does not confer upon such individual, or eligible dependent of such individual, any right to continued benefits under any Plan.
You may choose any licensed dentist practicing within the scope of his or her profession, or any physician furnishing dental services for which he or she is licensed. However, there are certain financial advantages if you choose a dentist who is participating in the United Concordia provider network.
The benefit covers work included in a broad list of dental services, divided into"preventive services", "basic services" and "major services." The full list appears later.
Many dental conditions can be treated properly more than one way. This coverage is designed to help pay dental expenses, but not on the basis of treatment that is more expensive than necessary for good dental care.
Thus, if a condition is being treated for which two or more services included in the list are suitable under customary dental practices, the benefit will be based on the listed service that, according to a determination made by the Claims Service Provider, would produce a professionally satisfactory result.
To demonstrate the application of the above provision, take two examples involving treatment of cavities in several front teeth. For example: It is determined that fillings would produce a professionally satisfactory result, but the patient decides to have the teeth crowned for the sake of appearance as the teeth are stained due to smoking. Here, the benefit would be based on the amount that would be provided for filling. Second example: It is determined that because of the condition of the teeth, crowns rather than fillings are required for a professionally satisfactory result. Here the benefit would be based on the use of crowns.
If a dental service is performed that is not on the list, but the list contains one or more other services that, under customary dental practices, are suitable for the condition being treated, then for the purpose of the plan the listed service that the Claims Service Provider determines would produce a professionally satisfactory result will be considered to have been performed.
Under the Penn State dental plan you have the choice of using participating or nonparticipating providers. If you use participating providers, located throughout the Commonwealth, you will receive the following advantages:
The annual deductible is the first $25 of eligible charges incurred by the individual during the calendar year. After two covered members in a family each have satisfied his or her annual deductible, benefits will be paid for covered dental charges incurred during the remainder of the calendar year for all covered family members without having to satisfy any additional deductibles.
Before you or a covered dependent have dental services which exceed $300, we urge you to obtain a "Treatment Plan" describing the dentist's proposed course of treatment. This Treatment Plan should be submitted to the Claims Service Provider and it will be returned to the dentist showing the estimated benefit. No treatment plan should be submitted if the total charges do not exceed $300 or if emergency care is required. A "Treatment Plan" is the dentist's report on a form satisfactory to the Claims Service Provided which (a) itemizes his or her recommended services, (b) shows his or her charge for each service, and (c) is accompanied by supporting preoperative X-rays where required or requested by the Claims Service Provider.
In the case of orthodontic procedures, we also urge you to have the dentist submit an "Orthodontic Treatment Plan" to the Claims Service Provider for review prior to treatment. The Claims Service Provider will return it to the dentist showing the estimated benefit. The "Orthodontic Treatment Plan," among other things, also provides a classification of the malocclusion or malposition, describes the recommended treatment, gives the estimated total charges and duration of treatment, and is accompanied by cephalometric X-rays, study models and other supporting evidence.
Although a benefit may be payable without approval by the Claims Service Provider, predetermination of benefits by means of submitting a treatment plan permits the review of the proposed treatment in advance and allows for resolution of any questions before , rather than after, the work has been done. Additionally, both you and the dentist will know in advance what is covered and what the estimated benefits are, assuming you or the dependent remains covered.
An "eligible charge" is one the dentist makes to you for a covered preventive, basic or major dental service furnished to you or a covered dependent, provided the service:
Participating providers have agreed to accept United Concordia's Maximum Allowable Charge (MAC) as payment in full for covered services, Participating providers will make no additional charge to Members for covered services, except in the case of certain coinsurances or amounts exceeding the program maximums.
Non-participating providers do not agree to accept United Concordia's MAC as payment in full for covered services, and may charge the member the difference between United Concordia's MAC and the provider's charge, including any coinsurances and amounts exceeding the program maximums.
A charge will be considered to be incurred on the date the service is received, rather than on the date the charge is made.
These benefits are payable for a covered individual (you or a covered dependent). The plan will pay 80% of the reasonable and customary charges for basic services and 100% for preventive services up to the maximum allowed under the plan for the rest of the calendar year, up to the maximum benefit.
This part of the Plan will pay 60% of the reasonable and customary charges for major dental services for the rest of the calendar year, up to the maximum benefit.
A Maximum Annual Benefit of $1,000 applies to all preventive basic and major services except orthodontic procedures. The maximum benefit for orthodontic procedures during a person's lifetime is $1,250. This benefit could be paid concurrently and in addition to the $1,000 nonorthodontic maximum. These maximums apply separately to you and each of your covered dependents.
The List includes only those services itemized below. Any services not listed will be excluded except as provided in the following paragraph.
If a charge is incurred for a service not included in this List in connection with the dental care of a specific condition, and if this List contains one or more services which, according to customary dental practices, are separately suitable for the dental care of that condition, then a charge will be considered to have been incurred for a service in the List which, as determined by the Claims Service Provider, would have produced a professionally satisfactory result.
If two or more services included in this List are separately suitable for the dental care of a specific condition, according to customary dental practices, and if a charge is actually incurred for one of such services, the Claims Service Provider may consider a charge to have been incurred for another service which, as determined by the Claims Service Provider, would have produced a professionally satisfactory result.
Bitewing films, including examination (not more than twice each calendar year)
Except for injuries, film fees include examination and diagnosis.
Includes local anesthesia and routine post-operative care.
General, only when provided in conjunction with a surgical procedure.
Emergency treatment (periodontal abscess, acute periodontitis, etc.)
Excluding inlays, crowns (other than stainless steel) and bridges. (Multiple restorations in one surface will be considered as a single restoration.)
Includes all adjustments within six months after installation.
Gold restorations and crowns are covered only when teeth cannot be restored with a filling material.
(Fees for dentures, partial dentures and relining include adjustments with six months after installation. Specialized techniques and characterizations are not eligible.)
Only when required by one or more of the following conditions:
An "orthodontic procedure" is defined as the movement of teeth by means of active appliances to correct the position of maloccluded or malpositioned teeth.
The Plan does not cover:
If the Dental Expense coverage is terminated, the protection will be extended to cover an Orthodontic Treatment plan then in progress for up to 3 months.
The claim procedure is so designed that if the estimated charge is more than $300, you and the dentist will clearly understand what the benefit covers and what the estimated benefits are, before the dental work is started. Another aspect of the procedure is that you may authorize payment to the dentist.
The claim will be paid in installments beginning when the orthodontic appliances are first inserted, and quarterly thereafter for the estimated duration of the treatment plan, as long as the patient remains covered. The installments will be in equal amounts, except that the initial payment will be twice the subsequent quarterly amounts.
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