The
Oklahoma State and Education Employees Group Insurance Board
For Plan Year January
1 through December 31, 2009
You
have access to your current plan information via the web. Using the ClaimLink
option from the HealthChoice home page, you can view your eligibility,
benefits, deductible, and claim status, as well as view and print copies of
your Explanations of Benefits. Registration is quick and easy. If you have any
questions, please contact the dental claims administrator.
You
can easily access the HealthChoice Network
Provider Directory
through the HealthChoice website. By clicking on the Provider Listings link on
the home page, you are routed to the Provider Directories page. By clicking on
the Network Medical or Dental Providers link, you can search for a HealthChoice
Network Provider.
The
Frequently Asked
Questions
link on our website provides an interactive application that allows you easy
access to general Plan information. You have the ability to search for information
by category, topic, or by listing a key word or phrase.
Audio
CDs and CD versions for PC of the handbooks have been prepared and are
available at the Oklahoma Library for the Blind and Physically Handicapped
(OLBPH). Contact the OLBPH at 1-405-521-3514 or toll-free 1-800-523-0288. TDD
users call 1-405-521-4672.
Plan Identification
Information and Notice
Outline of Dental Plan Benefits
Summary Schedule of Covered Benefits
Eligibility and
Effective Dates
Continuing coverage After Termination of Employment
Termination/Reinstatement
of Coverage
Revised
January 2009
HealthChoice
Dental Plan
Oklahoma
State and Education Employees Group Insurance Board (OSEEGIB)
3545
NW 58th Street, Ste 110
Oklahoma
City, OK 73112
1-405-717-8701
or toll-free 1-800-543-6044
HealthChoice
Member Services and Provider Directory
1-405-717-8780
or toll-free 1-800-752-9475
TDD:
1-405-949-2281 or toll-free 1-866-447-0436
Fax:
1-405-717-8942
Website:
www.sib.ok.gov or www.healthchoiceok.com
EDS
Administrative Services, LLC
Correspondence,
Claim Filing, and Claim Review Address
PO
Box 24870
Oklahoma
City, OK 73124-0870
1-405-416-1800
or toll-free 1-800-782-5218
TDD:
1-405-416-1525 or toll-free 1-800-941-2160
The
Oklahoma State and Education Employees Group Insurance Board (OSEEGIB) provides
dental benefits to eligible state, education, and local government employees,
former employees, survivors, and their dependents in accordance with the
provisions of Oklahoma Statutes, Title 74, Sections 1301, et
seq. The information provided in this handbook is a summary of the benefits,
conditions, limitations, and exclusions of the HealthChoice Dental Plan. It
should not be considered an all-inclusive listing.
OSEEGIB
Plan benefits are subject to conditions, limitations, and exclusions. These
conditions, limitations, and exclusions are described and located in Oklahoma
Statutes, OSEEGIB Rules, and Administrative Procedures adopted by the Plan
Administrator. You may obtain a copy of the official OSEEGIB Rules from the
Office of the Oklahoma Secretary of State. A copy of the Administrative
Procedures may be obtained from the OSEEGIB.
PLEASE
READ THIS HANDBOOK CAREFULLY
A
dispute concerning information contained within any OSEEGIB handbook or any
other written materials, including any letters, bulletins, notices, or other
written document, or oral communication, regardless of the source, shall be
resolved by a strict application of OSEEGIB Rules or benefit administration
procedures and guidelines as adopted by the Plan. Erroneous, incorrect,
misleading, or obsolete language contained within any handbook, other written
document, or oral communication, regardless of the source, is of no effect
under any circumstance.
This
dental handbook replaces and supersedes any dental handbook previously issued
to you. This dental handbook will in turn be superseded by any subsequent
dental handbook OSEEGIB issued to you.
This
handbook provides a quick guide to the basic dental plan benefits. Please read
this handbook carefully for explanations of the eligibility rules and what the
Plan pays, limits, and excludes.
The
benefits of the HealthChoice Dental Plan are based on cost-sharing features
that include deductibles and coinsurance. Plan benefits and your out-of-pocket
costs will differ depending on the provider you choose.
As
a HealthChoice member, you have the option to be treated by any dental provider
and the option to change dental providers at any time. You are encouraged to
use Network providers whenever possible because you will receive a higher level
of benefits.
The
HealthChoice Provider Network helps you manage your overall dental care needs
through a statewide and multi-state network. Network providers have agreed to
accept set fees, known as Allowed Charges, for the services and equipment they
provide.
HealthChoice
Network providers have agreed not to bill you for amounts greater than the
Plan’s Allowed Charges.
Non-Network
providers do not contract with HealthChoice, and are not limited by
HealthChoice Allowed Charges. You should be aware that when non-Network
services are used, you will be responsible for any amounts in excess of the
Allowed Charges.
To
locate a Network provider in your area, access the HealthChoice Telephone
Provider Directory by contacting the HealthChoice Telephone Provider Directory
at the phone numbers or web addresses located in the Plan Identification Information and Notice
section.
When
using a Network provider, the Plan provides the following benefits:
Preventive services covered at 100% of the
Allowed Charges
Basic restorative services covered at 85% of
the Allowed Charges
Major restorative services covered at 60% of
the Allowed Charges
A $25 per person calendar year deductible
for Basic and Major restorative services, or a combined $75 family calendar
year deductible
Orthodontia services for members under age 19, or members age 19 and over with TMD, are covered at 50 %
of the Allowed Charge. Orthodontia benefits may be subject to the 12-month
orthodontia waiting period. Refer to the Exclusions and Limitations section.
Network
providers will file your claims for you.
The
maximum calendar year benefit per person for Preventive, Basic, and Major
services combined is $2,000.
You
are responsible for all non-covered services and for amounts above the calendar
year maximum.
When
using a non-Network provider, the Plan provides the following benefits:
Preventive services covered at 100% of the
Allowed Charges
Basic restorative services covered at 70% of
the Allowed Charges
Major restorative services covered at 50% of
the Allowed Charges
A $25 per person calendar year deductible
for Preventive, Basic, and Major services, or a combined $75 family calendar
year deductible
Orthodontia services for members under age 19, or members age 19 and over with TMD, are covered at 50%
of the Allowed Charge. Orthodontia benefits may be subject to the 12-month
orthodontia waiting period. Refer to the Exclusions and Limitations section.
You
must file your claims with the dental claims administrator.
The
maximum calendar year benefit per person for Preventive, Basic, and Major
services combined is $2,000.
You
are responsible for all non-covered services, for amounts above the Allowed
Charge, and for amounts above the calendar year maximum.
You
must file your claims with the dental claims administrator.
Calendar
Year Deductible
None
Plan
Pays - of Allowed Charges
100%
Calendar
Year Deductible
$25**
Plan
Pays - of Allowed Charges
100%
Calendar
Year Deductible
$25*
Plan
Pays - of Allowed Charges
85%
Calendar
Year Deductible
$25**
Plan
Pays - of Allowed Charges
70%
Calendar
Year Deductible
$25*
Plan
Pays - of Allowed Charges
60%
Calendar
Year Deductible
$25**
Plan
Pays - of Allowed Charges
50%
Calendar
Year Deductible
None
Plan
Pays - of Allowed Charges
50%
Calendar
Year Deductible
None
Plan
Pays - of Allowed Charges
50%
*Network
Services – There is a $25 per person deductible per calendar year for Basic and
Major services combined. The calendar year family deductible for Basic and
Major services combined is $75.
**Non-Network
Services – There is a $25 per person per calendar year deductible for Preventive,
Basic, and Major services combined. The calendar year family deductible is $75.
Network
and non-Network deductibles accumulate separately.
There
is no deductible or lifetime maximum for Network and non-Network orthodontia
services; however, a 12-month waiting period may apply. Refer to the Exclusions and Limitations section.
You
are responsible for non-Network amounts that exceed the Allowed Charges and for
all non-covered services.
The
following maximum benefit applies per person and does not include deductibles.
$2,000 per calendar year per person for
Preventive, Basic, and Major services combined.
You
are responsible for all charges above the $2,000 calendar year benefit maximum
for Preventive, Basic, and Major services. Once you have exhausted your $2,000
calendar year benefit, your provider is not limited to the Allowed Charge set
by HealthChoice.
Covered
services include
Teeth cleaning, bitewing x-rays, routine
oral examinations, two covered per calendar year
Topical fluoride treatment for dependent
children under 16, two covered per calendar year
Full mouth x-rays, one covered per 36 months
Supplemental bitewing x-rays, two covered
per calendar year.
Space maintainers, to replace prematurely
lost teeth for covered dependent children under age 19
Emergency palliative treatment
Sealants on permanent teeth for covered
dependents through age 16, reapplication is not covered
Covered
services include
Extractions, including wisdom teeth
Oral surgery, including general anesthesia
Amalgam, silicate, acrylic, synthetic
porcelain, and composite filling restorations to restore diseased or fractured
teeth
Certain treatments of periodontal disease
Endodontic treatment, root canal therapy,
injection of antibiotic medications
Repair or recementing of bridges, crowns,
inlays, onlays, or dentures
Relining or rebasing of dentures once every
three years, except during the first six months after the initial installation
or replacement of the denture
Covered
services include
Initial placement of full
or partial removable dentures, fixed bridge work, replacement of existing
partial, or an addition of teeth to a partial removable denture or bridgework
as covered by the Plan. The existing denture or bridgework must have
been installed at least five years prior to its replacement and cannot be
repairable, or the existing denture must be an immediate temporary denture that
cannot be made permanent. Replacement with a permanent denture must take place
within 12 months of the initial installation of the temporary denture.
Dental implant systems approved by the Food
and Drug Administration (FDA). Prior approval is required.
Inlays, onlays, gold fillings, or crown
restorations to restore diseased or fractured teeth, but only when the tooth,
as a result of extensive cavities or fracture, cannot be restored to proper
function with amalgam, silicate, acrylic, synthetic porcelain, or composite
restoration.
Covered
services include
Orthodontic expenses for members under age
19
Orthodontic services for treatment of temporomandibular
joint dysfunction for members age 19 and older
Molar uprighting
Note
– There is no deductible or lifetime maximum for Network and non-Network
orthodontia services; however, a 12-month waiting period may apply. Refer to
the Exclusions and Limitations section.
Please
contact the dental claims administrator if you have questions about what
orthodontia treatments can be started during the waiting period without
jeopardizing your entire benefit.
The
waiting period may not apply if you or your dependents had group dental
coverage in force up to the effective date of the HealthChoice coverage. Proof
of other group dental coverage must be submitted at the time of enrollment.
There
is no coverage for the following items. This list is not all-inclusive.
1. Dental care and supplies that are furnished
in a facility operated under the direction of, or at the expense of, the U.S.
Government, or its agency, or by a provider employed by such a facility.
2. Dental care and supplies for which there is
no charge made, or no payment would be required, if the insured individual did
not have coverage.
3. Dental care and supplies provided by a
denturist.
4. Dental care and supplies that result from
taking part in committing, or attempting to commit, an assault or felony.
5. Dental care and supplies due to sickness or
injury covered by Workers’ Compensation, occupational disease law, or similar
laws.
6. Dental care and supplies to the extent that
they are payable under other provisions of the policy.
7. Dental care and supplies as a result of an
Act of War, declared or undeclared, insurrection, or release of nuclear energy.
8. Charges incurred after the covered
individual’s benefit ends.
9. Supplies and prescription drugs for care or
treatment, other than those used in a dentist’s office, or instructions in
dental hygiene. Prescription drugs prescribed by your dentist may be covered by
your health plan.
10. Expenses relating to an intentionally
self-inflicted injury.
11. Hospital confinement and ancillary services,
including anesthesia, for dental surgery when the confinement is necessary due
to illness or other health conditions. These charges should be filed with your
medical plan.
12. Replacement of lost dentures.
13. Separately billed infection control fees.
14. Charges for missed or canceled appointments.
15. Gel-Kam and other take home fluorides.
16. Oral care and supplies which are used to
change vertical dimension or closure except as provided under Orthodontia
benefits.
17. Adult orthodontics without a diagnosis of
temporomandibular joint dysfunction.
18. Cosmetic procedures.
19. Charges made by a duly qualified dentist or
oral surgeon for treatment of fractures and dislocations of the jaw, or for
cutting procedures and treatment. These charges should be filed with your
medical plan.
20. Medical expenses for the treatment of
temporomandibular joint dysfunction.
21. Medical services treating an oral condition.
22. Services supplied by a provider who is a
relative by blood, or by marriage of the patient, or one who normally lives
within the patient’s home.
23. Separately billed local or block anesthesia
used in conjunction with restorative and/or surgical procedures.
If
group dental coverage was not in effect immediately prior to your being covered
under this Plan, there will be a 12-month waiting period before orthodontia
benefits will be available and no benefits will be paid for any orthodontia
treatment during that time period. You must be covered under the HealthChoice dental
plan for 12 months and the banding must occur after the 12-month waiting
period. Please contact the dental claims administrator if you have questions
about what orthodontia treatments can be started during the waiting period
without jeopardizing your entire benefit.
This
limitation may not apply if you or your dependents have had continuous group
dental coverage. The orthodontia limitation may be waived if all of the
following conditions are met.
There has been no break in coverage
You can provide proof of loss of other group
dental coverage
The request for coverage is submitted within
30 days of loss of other coverage
Example 1
A
dependent is enrolled in HealthChoice dental effective 10-1-09, and is subject
to the orthodontic waiting period. The dependent receives an appliance made on
1-5-10 that costs $500. Banding for braces of $6,000 is done 9-1-10. Under this
scenario, no orthodontia benefits are paid for the appliance or the braces.
Example 2
Next
scenario is identical to Example 1, except that the banding occurs 12-15-10. In
this case, no benefits are available for the appliance, but benefits are
available for the braces.
Example 3
Coverage
is effective 2-1-09, and banding for braces occurs 12-16-09. No benefits are
payable for braces. An appliance that costs $500 is made 6-1-10, and is
eligible for benefits.
Dental
accidents are covered under the HealthChoice Health Plan which pays for
medically necessary treatment for the repair of injury to sound natural teeth
or gums. You must be a participant in the HealthChoice Health Plan and
treatment must be performed within 12 months following the accident. If you are
enrolled in another health plan, contact that plan for information on how
dental accidents are covered.
To
be covered, certain procedures, including dental implants, require
certification by HealthChoice. Providers must submit requests for these
procedures to the dental claims administrator and receive certification prior
to services being performed.
Your
provider will file the claim for you and payment is automatically made to your
provider.
You
may have to file your claims personally. Claims should be filed as soon as the
services are received or completed. A claim form is not needed. To file a
claim, send a copy of the bill including your name and ID number, the patient’s
name, and codes for procedures performed. This information can be obtained from
the provider. Send your claim to the dental claims administrator at the address
listed in the Plan Identification
Information and Notice section.
Non-Network
claims are usually paid to you; however, you may choose to assign benefits
directly to your provider.
When
a valid assignment of benefits to your provider is submitted with the claim,
payment will be made to your provider. When there is no valid assignment of
benefits, payment will be made to you and you will be responsible for paying your
provider.
Claims
must be received no later than the last day of the calendar year following the
year of the date the claim was incurred. For example, if the date of service
was July 1, 2009, the claim will be accepted through December 31, 2010. After
December 31, 2010, the claim would not be eligible for payment under the timely
filing rule.
If
you receive services outside the United States, the following claim procedures
must be met.
You must make arrangements to pay for the
services or supplies
You must submit a claim
All claims must be translated into English
and converted to U.S. dollar amounts using the exchange rates applicable for
the dates of service; you must file the original claim along with the
translation
The Plan does not pay any costs for translating
claims or dental records
Allowed Charges will be paid at the
non-Network rate of coinsurance; you will be responsible for amounts above the
Allowed Charges
If
you or your enrolled dependents incur charges covered by another group dental
plan, the benefits of each plan will be coordinated so the total benefits
received are not greater than the charges billed, or greater than your
liability,
When
a VOIC form is needed in relation to the processing of a claim, the dental
claims administrator will request one from you. Failure to provide a VOIC when
requested will cause your claim to be delayed or denied for non-compliance.
If
a dental treatment is expected to cost more than $200 for Preventive, Basic, or
Major covered services, a pre-estimate of the benefits
payable is recommended. A pre-estimate is filed like a claim and provides you
with an overview of the costs of your treatment and the amount of benefits the
Plan will pay. The pre-estimate should be submitted before treatment begins and
include any required supportive documentation.
Your
dentist or specialist must bill for the exact services pre-estimated, unless
you make a request for additional services.
If
your claim is denied in whole or in part for any reason, you have the right to
have your claim reviewed. Requests for review of your denied claim, along with
any additional information you wish to provide must be submitted in writing to the
dental claims administrator at the claims review address or call the dental
claims administrator at the numbers provided in the Plan Identification Information and Notice
section.
If
your claim remains denied after a claims review, you may appeal that decision
to the Grievance Panel by contacting
The
Legal Grievance Department
3545
NW 58th St, Ste 110
Oklahoma
City, OK 73112
Or
call 1-405-717-8701 or toll-free 1-800-543-6044. TDD users call 1-405-949-2281
or toll-free 1-800-447-0436.
The
Grievance Panel is an independent review group as established by statute 74
O.S. Section 1306(6).
All
requests for hearings must be filed within one year from the date you are
notified of the denial of a claim, benefit, or coverage.
You
may submit a request for a Grievance Panel hearing and represent yourself in
these proceedings. If you are unable to submit a request for a Grievance Panel
hearing yourself, only attorneys licensed to practice in Oklahoma are permitted
to submit your hearing request for you, or to represent you through the hearing
process 75 O.S. Section 310(5).
All
claim reviews and final decisions of the Grievance Panel are made as quickly as
possible. After completing the claim review and grievance
procedures, an appeal may be pursued in an Oklahoma District Court.
Subrogation
applies when you are sick or injured as a result of the negligent act or
omission of another person or party. Subrogation means the HealthChoice Plans
have a right to recover any benefit payments made to you, or your dependents,
by a third party’s insurer, because of an injury or illness caused by the third
party. Third party means another person or organization.
If
you or your covered dependents receive HealthChoice benefits and have a right
to recover damages from a third party, this plan has the right to recover any
benefits paid on your behalf. All payments from a third party, whether by
lawsuit, settlement, or otherwise, must be used to repay HealthChoice.
You
must promptly notify HealthChoice if you make a claim against a third party
regarding any illness or injury for which HealthChoice benefits have been or
will be paid. You, or your dependent, must provide information requested by
HealthChoice. HealthChoice benefits may be withheld until information is
received.
After
any requested information is received from you, HealthChoice will process your
covered claims, regardless of whether any third party may eventually be found
liable for the expenses arising from the injury.
For
more information about subrogation, contact OSEEGIB. Do not contact the dental claims
administrator regarding subrogation as this will only delay a response.
You
may choose any provider or practitioner who is licensed or certified under the
laws of the state in which they practice, and who is recognized by the Plan.
Each provider offering dental care service is an independent contractor. The
provider retains the provider-patient relationship with you and is solely
responsible to you for dental advice and treatment or any subsequent liability
resulting from the advice or treatment.
Although
a provider may recommend or prescribe a service or supply, this does not necessarily
establish coverage by the Plan.
For
information on what types of providers are recognized by the Plan, contact
HealthChoice Provider Relations at 1-405-717-8790 or toll-free 1-800-543-6044.
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436, or check the
Frequently Asked Questions on the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com.
Coverage
obtained by means of inaccurate or erroneous information will be canceled
retroactive to the effective date, and premiums for coverage refunded. The
refunded premiums will be reduced by any claims paid by HealthChoice during
that time.
When
you enroll or make changes to your coverage, you will be mailed a Confirmation
Statement (CS). The CS will list the coverage in which you are enrolled, the
effective date of the coverage, and the premium amounts for the coverage.
You
should review your CS to ensure that the coverage listed is correct. Any
corrections must be submitted within 60 days of the election. For current
employees, corrections must be submitted to your Insurance/Benefits
Coordinator. For former employees, you must submit corrections to OSEEGIB. Corrections
reported after 60 days will be effective the first of the month following
notification.
OSEEGIB
shall retain the right to recover any payments made by the Plan in excess of
the maximum allowable expenses, as set forth in the Plan. OSEEGIB shall have
the right to recover such payments, to the extent of excess, from one or more
of the following
Any persons to, or for, or with respect to
whom such payments were made
Any other insurers
Service plans or any other organizations
You
are eligible to participate in the HealthChoice Dental Plan if you are
A current Education employee eligible to
participate in the Oklahoma Teachers’ Retirement System and working a minimum
of four hours per day or 20 hours per week.
A current State of Oklahoma or Local
Government employee regularly scheduled to work at least 1,000 hours a year and
not classified as a temporary or seasonal employee.
Coverage
for new employees becomes effective the first day of the month following your
entry-on-duty date or the date you become eligible with a participating employer.
If you wish to make changes to the coverage you initially elected, you have a
30-day window following the date you became eligible to make benefit changes.
These changes are effective the first day of the month following the date the
change is made.
Note
– Orthodontia benefits may be subject to a 12-month waiting period. For
additional information refer to the Exclusions and Limitations section.
You
must be enrolled in a group health plan in order to enroll yourself and your
dependents in the dental plan. If dependent coverage is selected, all of your
eligible dependents must be covered unless they are covered under another group
dental plan, or are eligible for Indian or military dental benefits.
If
you are enrolled and have a new dependent as a result of marriage, birth,
adoption, or placement for adoption, you may enroll your dependents provided that
you request enrollment within 30 days following the marriage, birth, adoption,
or placement for adoption. All other enrollments must be made during the annual
Option Period and some limitations may apply. Refer to the Exclusions and Limitations section.
Eligible
dependents include
Your legal spouse (including common-law*)
Your unmarried children up to age 25
provided you are primarily responsible for their support
Your dependent,
regardless of age, who is incapable of self-support, and who has a disability
that was diagnosed before the age of 25, subject to medical review and approval
Your stepchildren, provided you are
primarily responsible for their support, or regardless of residence if your
spouse has been court ordered to provide coverage and your spouse is also
covered
Other dependent children - in the absence of
a federal income tax return listing the children as dependents, you will be
required to provide and have approved a Declaration of Dependency form
*Common-law
marriages are recognized by the Plan. A new employee can add a common-law
spouse at the same time the employee enrolls. A current employee can request
coverage on a common-law spouse during the annual Option Period, or in the
event the common-law spouse loses other group coverage. To enroll a common-law
spouse, the employee and spouse must sign and submit an Enrollment/Change Form.
Eligible
dependents can be excluded from coverage if they have other group dental
coverage or are eligible for Indian or military dental benefits.
You
may elect to exclude your spouse from coverage. You and your spouse must both sign
the Spouse Exclusion section of your Enrollment/Change Form.
A
dependent who is no longer eligible may apply for continuation of coverage under
COBRA for a maximum of 36 months. Refer to the Continuing Coverage After
Termination of Employment section for more information.
Note
– If your spouse is also a primary member of a HealthChoice plan through his/her
employer, dependent children may be covered under either parent’s dental plan,
provided the parent is also enrolled in the dental plan. Dependent children
cannot be covered under both parents’ plan.
If
you previously declined enrollment in the dental plan because you had other
group dental insurance coverage, Indian or military dental benefits, you may
enroll
Within 30 days after the date your other
group coverage ends
During the annual Option Period
Certain
qualifying events may allow a midyear benefit change; however, an
Enrollment/Change Form must be completed within 30 days of the qualifying
event. Examples of midyear qualifying events include
A change in your legal marital status, such
as marriage, divorce, or death of spouse
A change in the number of your dependents,
such as the birth of a child
A change in employment status that affects
your eligibility or that of your spouse or dependent
An event that causes your dependent to meet,
or fail to meet eligibility requirements
Commencement or termination of adoption
procedures
Any judgments, decrees, or orders (employer
may allow changes only to health and dental)
Changes in the coverage of your spouse or
dependent under another employer’s plan
Eligibility for leave under the Family
Medical Leave Act (FMLA)
You
may only make changes to coverage within 30 days of a qualifying event or
during the annual Option Period.
All
changes to coverage must be in compliance with the rules of your employer’s
Section 125 Plan, or if no 125 Plan is offered, in compliance with allowed
midyear coverage changes as defined by Title 26, Section 125, of the Internal
Revenue Codes, as amended, and pertinent regulations.
Current employees must contact their Insurance/Benefits Coordinator for an
Enrollment/Change Form to make changes in coverage.
You
may make eligible changes only within 30 days of a qualifying event. Dependents
or new benefit plans other than vision, cannot be
added during the annual Option Period.
Former
employees and surviving dependents must submit a written request for changes in
coverage to
Oklahoma
State and Education Employees Group Insurance Board
3545
NW 58th, Ste 110
Oklahoma
City, OK 73112
Verbal
requests for changes in coverage will not be accepted.
Note
– Oklahoma law prohibits dropping your spouse/dependents in anticipation of a
divorce or legal separation. If you are in the process of separation or
divorce, it is important that you contact your legal counsel for advice before
making any changes to your benefits coverage.
Under
the Uniform Services Employment and Re-employment Rights Act of 1994 (USERRA),
coverage can be continued for up to 24 months. USERRA provides certain rights
and protections for all employees called to serve our nation. All branches of
the military including the Army, Navy, Marines, Air Force, Coast Guard, all
Military Reserve units, and all National Guard units come under USERRA.
In
addition to health care provided by the military, you have the following four
choices regarding your current coverage
1.
Keep all coverage. Your current employer is responsible for collecting and
forwarding all premiums to OSEEGIB.
2.
Discontinue member coverage but keep dependent coverage. This is the COBRA
option and dependents will be billed directly at 102% of premiums, the COBRA
rate, for health, dental, and/or vision coverage. Under COBRA rules, life and
disability insurance cannot be retained.
3.
Discontinue all coverage except life insurance. You will be billed directly.
4.
Discontinue all member and dependent coverage.
Regardless
of whether you receive written or verbal military orders, the OSEEGIB staff,
and/or your Insurance/Benefits Coordinator will assist you in making any
benefits arrangements.
There
is no penalty for renewing coverage upon discharge from active duty if coverage
is elected within 30 days of your return to the same employment.
If
you are a member of a Military Reserve unit or the National Guard and
anticipate being called to active service, notify your Insurance/Benefits
Coordinator at work.
You
may also obtain coverage for certain other dependents if they are legally
adopted, you have legal guardianship, or the dependents meet other specific
requirements. You must
Request coverage within the time frame
specified in each category listed in this section
Provide the necessary documentation
Meet all eligibility requirements
Pay all premiums
Cover all eligible dependents
An
adopted dependent is eligible for coverage the first day of the month in which
you obtain physical custody. You must submit an Enrollment/Change Form to HealthChoice,
including a copy of your adoption papers. In the absence of adoption papers or
other court records, someone involved in the adoption process, such as your
attorney or a representative of the adoption agency, must provide proof of the
date you actually received custody of the child pending the final adoption
hearing.
You
must request coverage within 30 days of the date of the initial placement for
adoption, otherwise
Current employees cannot add coverage until
the next annual Option Period
Former
employees are not allowed to add coverage at any later date
Guardianship
follows the same guidelines as an adoption, except that coverage will not begin
until the first day of the month following the date the child was placed in
your custody.
In
the absence of a court order indicating adoption, guardianship, or divorce, you
may request coverage for other eligible dependents by submitting an
Enrollment/Change Form with a copy of the portion of your most recent income
tax return that lists the children as dependents for income tax deduction
purposes.
Coverage
for other eligible dependents begins on the first day of the month following
the date you obtained physical custody and never applies retroactively.
In
the absence of a federal income tax return listing the children as dependents,
you will be required to provide a Declaration of Dependency Form as specified
by the Plan. Coverage, when approved, begins on the first day of the month
following approval and never applies retroactively.
You
must request coverage within 30 days of the date of initial placement,
otherwise
Current employees cannot add coverage until
the next annual Option Period
Former employees are not allowed to add
coverage at any future date
Note
– The Plan retains the right to verify the dependent status of the children, to
request copies of that portion of your most recent income tax return that lists
the children as dependents, and to discontinue coverage for any dependents that
are found ineligible for coverage.
You
may have elected not to enroll in the HealthChoice Dental Plan because you were
covered under another group dental plan. If you later lose coverage under your other
group dental plan, you may enroll in the HealthChoice Dental Plan provided the
election is made within 30 days following the loss of other group dental
coverage. If your previous coverage is in effect the day before your
HealthChoice coverage becomes effective, no plan limitations will apply. If
your previous coverage is not in effect the day before your HealthChoice
coverage becomes effective or the coverage was individual coverage, benefit
limitations may apply. In order to avoid plan limitations, you may elect to have
your HealthChoice coverage begin on the first day of the month in which your
other group coverage was lost. This option is subject to payment of the full
premium for that month; otherwise, coverage shall become effective under this
Plan on the first day of the month following your election.
Participating
former employees may add eligible dependents within 30 days of loss of other
group dental insurance under which the dependents were covered.
Loss
of another type of group coverage, such as health coverage, does not grant the
right to enroll in the dental plan. Loss of group dental coverage does not
grant the right to enroll in other types of HealthChoice plans, such as health
or life.
Each
month, you must pay the full premium for the coverage you have selected.
Failure to pay premiums on a timely basis will result in your coverage
terminating at the end of the month for which the last premium was received.
If
you are on approved leave without pay through your employer, you may continue
coverage for up to 24 months from the first day you begin leave without pay
status. You must make timely premium payments in full each month to your
Insurance/Benefits Coordinator.
If
your coverage terminates for failure to pay premiums on a timely basis, you may
re-enroll as a new employee upon returning to work.
If
you take leave under the Family Medical Leave Act (FMLA), please make premium
payment arrangements with your employer before taking leave.
If
you leave employment, you and/or your covered dependents may be able to keep
coverage under the Plan through one of the following options:
Vesting or retirement rights through one of
the public employee retirement systems established by the State of Oklahoma
Years of service with state, education, or
local government employers; more information on Years of Service follows
Receiving benefits through the HealthChoice
Disability Plan administered by OSEEGIB
Survivors’ Rights for your covered
dependents in the event of your death
COBRA – Consolidated Omnibus Budget
Reconciliation Act
Each
month, premiums must be paid in full for coverage selected. Failure to pay
premiums on a timely basis will result in termination of coverage at the end of
the month for which the last premium was received.
You
may keep coverage after leaving employment if you make an election within 30
days following your termination date, and you meet one of the following
conditions:
You are eligible to participate in the
Oklahoma Public Employees Retirement System and have eight or more years of
service with a participating employer, but do not have a vesting right
You are eligible to participate in the
Oklahoma Teachers’ Retirement System and have ten or more years of service with
a participating employer
You are an employee of an education employer
that participates in the Plan but does not participate in the Oklahoma
Teachers’ Retirement System, and have ten or more years of service
You are an employee of a local government
employer that participates in the Plan but does not participate in the Oklahoma
Public Employees Retirement System, and have eight or more years of service
If
you were a career tech employee or a common school employee who terminated
active employment on or after May 1, 1993, you may continue coverage through
the Plan as long as the school system from which you retired or vested
continues to participate in the Plan. If your school system terminates coverage
under the Plan, you must follow your school system to its new insurance
carrier. If you retired prior to May 1, 1993, you have the option to continue
coverage with OSEEGIB or follow your entity to its new insurance carrier.
If
you were an employee of an education entity other than a common school; e.g.,
higher education, charter school, etc., you may continue coverage through the
Plan as long as the education employer from which you retired or vested
continues to participate in the Plan. There is no grandfathered date for this
type of entity, so if your employer terminates coverage with the Plan, you must
follow your former employer to its new insurance carrier regardless of the date
you terminated active employment.
If
you were a local government employee who terminated active employment on or
after January 1, 2002, you may continue coverage through the Plan as long as the
local government employer from which you retired or vested continues to
participate in the Plan. If your local government employer terminates coverage
with the Plan, you must follow your former employer to its new insurance
carrier. If you retired prior to January 1, 2002, you have the option to
continue coverage with OSEEGIB or follow your entity to its new insurance
carrier.
Note
- You cannot reinstate coverage that you discontinue or allow to lapse unless
you return to work as an employee of a participating employer and maintain that
coverage for three years. Some reinstatement exceptions may apply if you are a
state employee who terminated employment as a result of a Reduction in Force –
RIF.
For
any group that joins the Plan after the grandfathered dates previously
specified, all members, including current and former employees, must follow the
group to the new insurance carrier.
You
may keep dental coverage in effect as an employee if you are receiving benefits
through the HealthChoice Disability Plan. You may continue coverage as long as
you are covered under the HealthChoice Disability Plan and pay premiums in a
timely manner. You must maintain continuous coverage. If you discontinue
coverage, or allow coverage to lapse, it cannot be reinstated unless you return
to work as an employee of a participating employer.
Your
surviving spouse and dependents have 60 days following your death to notify
OSEEGIB that they wish to continue coverage. Coverage will be effective the
first day of the month following your death.
Your
surviving spouse is eligible to continue insurance coverage as long as premiums
are paid.
Surviving
dependent children are eligible for coverage until age 25 or the child marries.
Disabled
dependent children will be eligible to continue survivors’ coverage as long as
they continue to meet the HealthChoice definition of a disabled dependent.
Note
- COBRA continuation of coverage is available for dependent children who lose
eligibility.
If
you or your dependents coverage is terminated for any of the reasons that
follow, each covered member has the right to elect temporary continuation of
coverage through COBRA.
You
are eligible for limited continuation of coverage, up to 18 months, if you lose
coverage due to
A reduction in your hours of employment
Termination of your employment for reasons
other than gross misconduct
Your
covered spouse is eligible for limited continuation of coverage if his/her coverage
is lost due to
Your death – also refer to Survivors’ Rights
Termination of your employment for reasons
other than gross misconduct
A reduction in your hours of employment
resulting in loss of coverage
A divorce or legal separation*
Your
covered dependent children are eligible for limited continuation of coverage if
coverage is lost due to
Your death – also refer to Survivors’ Rights
Termination of your employment for reasons
other than gross misconduct
A reduction in your hours of employment resulting
in loss of coverage
A divorce or legal separation of the
parents*
Your dependent no longer meets the
requirements for dependent status
*Oklahoma
law prohibits dropping your spouse/dependents in anticipation of a divorce or
legal separation. If you are in the process of a legal separation or divorce,
it is important you contact your legal counsel for advice before making changes
to your benefits coverage.
If
you are a participating current employee, it is your responsibility to notify
your employer within 30 days of a divorce, legal separation, or your child’s
loss of dependent status under this Plan.
If
you are a former employee, you must notify OSEEGIB in writing within 30 days of
a divorce, legal separation, or your child’s loss of dependent status under
this Plan.
You
or your eligible dependents must elect continuation of coverage within 60 days
after the later of the following events occurs
The date the qualifying event would cause
you or your dependent to lose coverage
The date your employer notifies you or your
dependents of continuation of coverage rights
If
the qualifying event is related to termination of employment or reduced hours,
the coverage may be continued for a maximum period of 18 months. If the
qualifying event is for any other eligible reason, the coverage may be
continued for a maximum period of 36 months. However, continuation of coverage
will terminate immediately for you and/or all covered dependents under the
following circumstances
The Plan ceases to provide coverage
The required premiums are not paid in a
timely manner
You and/or your dependents become covered
under another group dental plan
If
you have additional questions regarding COBRA, contact your Insurance/Benefits
coordinator or OSEEGIB.
If
you elect to continue coverage under COBRA, an extension of the maximum period
of coverage may be available if a qualified beneficiary is disabled or a second
qualifying event occurs. You must notify OSEEGIB of a disability or second
qualifying event in order to extend the coverage continuation period. Failure
to provide timely notice of a disability or second qualifying event may affect
your right to extend the coverage continuation period.
Your
coverage, as well as any dependent coverage, ends on the last day of the month
one or more of the following events takes place
You terminate employment with a participating
employer and choose not to continue coverage through vesting, non-vest,
retirement, disability, or COBRA
You do not pay the required premiums
The Plan is terminated
Your death occurs
In
addition, a dependent’s coverage will end on the last day of the month he/she
ceases to be an eligible dependent. Upon review by OSEEGIB, if you or your
dependent is found to be ineligible, coverage will be terminated effective on
the first day of the month of discovery. OSEEGIB reserves the right to recover
any claims paid on behalf of an ineligible member.
If
you are currently employed by a participating employer and discontinue coverage
on yourself or your dependents, you cannot apply for reinstatement of coverage
for at least 12 months. To reinstate discontinued coverage, you must enroll
within 30 days of
The expiration of the 12 month period; if
coverage is not reinstated within 30 days of the end of the waiting period, you
cannot enroll in coverage until the next annual Option Period
The loss of other group dental coverage or
other qualifying event
To
reinstate coverage, proof of the loss of other group coverage or other
qualifying event must be submitted. If coverage is not continuous between the
two plans, the 12-month orthodontia waiting period will apply. Refer to the Exclusions and Limitations section.
Reinstated
coverage must be maintained for three years to allow you to carry it into
retirement.
If
you or your covered dependents lose dental coverage while undergoing treatment,
the Plan still continues to provide benefits for two months following
termination of coverage. The Plan will pay the Allowed Charges in the following
situations according to Plan benefits
For dentures, denture impressions must be
taken before coverage ends
For bridgework, crowns, and gold
restoration, the tooth must be prepared before coverage ends and must be
installed within the extended benefit period
For endodontics, including root canal, the
tooth has to be opened before coverage ends; all covered services must be provided
and the Allowed Charge must be incurred
If
you are a former state employee who
Had a vested or retirement benefit based on
the provisions of any of the state public retirement systems,
Was separated from state service as a result
of a reduction in force anytime after July 1, 1997, and
Was offered severance benefits
pursuant to the State Government Reduction in Force and Severance Benefits Act.
You
may reinstate dental insurance coverage at any time within two years following
the date of the reduction in force from the state. Reinstated coverage must be
maintained for three years to allow you to carry it into retirement.
For
further information, contact HealthChoice Member Services at the numbers in the
Plan Identification Information and Notice
section.
This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review it
carefully.
OSEEGIB is a State of
Oklahoma governmental agency created and governed by Oklahoma law for the
purpose of administering health, life, disability, and dental
This notice describes
and gives you examples of the permitted ways your health information may be
used and disclosed.
OSEEGIB uses and
discloses your protected health information for your treatment, payment for
services, and OSEEGIB business operations in the administration of health
plans. The health claims you submit, or health claims submitted by providers
for your treatment, contain protected health information and are processed for
payment and data collection by claims administrators according to Oklahoma law
and contractual terms of confidentiality with OSEEGIB. Your health information
is used and disclosed by OSEEGIB employees and other entities under contract
with OSEEGIB according to the ‘minimum necessary’ standard. OSEEGIB or its
claims administrators may use and disclose health information, to determine
medical necessity for pre-certification of hospital and medical
You have the right
to: a) inspect and copy your health information, (generally EOBs) with the
exception of psychotherapy notes and/or information that requires a court
order; b) amend and restrict the health information that OSEEGIB discloses
about you; however, OSEEGIB is not required to agree to a requested
restriction; c) request your communications remain confidential with OSEEGIB;
d) receive a copy of this Notice; e) file a complaint if you believe OSEEGIB
has improperly used or disclosed your information; f) request a listing of
disclosures, except for treatment, payment, business operations, and per your
authorization after April 14, 2003; and g) receive a paper copy of this Notice
upon request if you have received this Notice electronically.
OSEEGIB reserves the
right to change the terms of this Privacy Notice and will provide all
interested persons a revised notice either by U.S. Postal Service delivered to
the individual’s mailing address on file with OSEEGIB or electronic
communication by posting the revised Privacy Notice on the OSEEGIB website at www.healthchoiceok.com and www.sib.ok.gov
If you believe your
privacy rights have been violated, call or send a written complaint to the
OSEEGIB HIPAA Information Officer at 3545 NW 58th, Suite 110, Oklahoma City,
Oklahoma, 73112, 1-405-717-8701, toll-free 1-800-543-6044, TDD 1-405-949-2281,
or toll-free TDD 1-866-447-0436; the Secretary of the U.S. Department of Health
and Human Services (HHS) at the Office of Civil Rights, 1301 Young Street, Ste
1169, Dallas, Texas, 75202, 1-214-767-4056, or submit an electronic complaint
according to directions located on the HHS Office of Civil Rights website.
Complaints to HHS must be filed within 180 days after the date on which you became
aware, or should have been aware, of the violation. No retaliation is allowed
against the individual filing a complaint.
Revised Notice
effective August 5, 2005
The set dollar amount allowed under the Plans for a
covered service or supply.
The
percentage of Allowed Charges that will be paid by you and by HealthChoice once
your deductible is satisfied.
A procedure that primarily serves to improve appearance.
The
initial amount of out-of-pocket expense you pay on Allowed Charges before a
benefit is paid by the Plan.
Your legal spouse
(including common-law).
Your unmarried children up to age 25 provided
you are primarily responsible for their support
Your dependent,
regardless of age, who is incapable of self-support, and who has a disability
that was diagnosed before the age of 25, subject to medical review and approval
Your stepchildren, provided
you are primarily responsible for their support, and regardless of residence if
your spouse has been ordered by the court to provide coverage and your spouse
is also being covered.
Other dependent children; in the absence of
a federal income tax return listing the children as dependents, you will be
required to provide and have approved a Declaration of Dependency form
An
employee of a participating employer who receives compensation for services
rendered and is listed on that employer’s payroll. This includes persons
elected by popular vote (i.e., board members for education and elected
officials of state and local government, state employees, rural water district
board members, county election board secretaries, and any employee otherwise
eligible who is on approved leave without pay, not to exceed 24 months).
Education employees must be eligible to
participate in the Oklahoma Teachers’ Retirement System and work a minimum of four
hours per day or 20 hours per week
Local government employees, including rural
water districts, must be employed in a position requiring a minimum of 1,000
hours work per year
An
employee who is participating in any of the Plans authorized by or through the
State and Education Employees Group Insurance Act who retired or vested their
rights with a state funded retirement plan, or has the required years of
service with a participating employer.
Any
eligible employee and/or eligible dependents who
waived coverage or failed to enroll within 30 days of the initial enrollment
offering, or any participating member or dependent who voluntarily terminates
coverage and re-enrolls.
A
provider who has entered into a contract with OSEEGIB to accept the Plan’s
Allowed Charges for services and/or supplies provided to Plan participants.
Any
service, procedure, or supply excluded from coverage and not paid for by the
Plan.
The
annual time period established by OSEEGIB in which changes may be made to
coverage.
The Oklahoma State and Education Employees Group
Insurance Board.
The
amounts for which you are responsible based on the use of Network or
non-Network services, including deductible and coinsurance. You will still be
responsible for all amounts above the Allowed Charges when using non-Network
providers.
A
waiting period for orthodontia benefits for the first 12 months of coverage.
Refer to Exclusions and Limitations section.
Any
municipality, county, education employer, or other state agency whose employees
or members are eligible to participate in any plan authorized by or through the
State and Education Employees Group Insurance Act.
The
HealthChoice dental insurance plan offered through OSEEGIB and described in
this handbook.
Note
– The following definitions are included for your convenience as a general
guide to specialized dental terms. The following descriptions should not be
interpreted as the official definitions of the American Dental Association or
of this Plan.
A mixture of two or more metals in combination with
mercury that is generally used as a restorative material.
The loss of sensation or feeling with or without the loss
of consciousness.
Front;
the first six teeth in the upper and lower jaw.
X-ray
film, generally diagnostic, used to detect the presence of dental decay.
A
fixed appliance replacing missing or extracted natural teeth that is supported
and held by attachments to restored, abutment, teeth and that is usually not
removable.
Reproduction
of the form of all or part of the dental arch, teeth and tissues, made from
plaster or stone.
Pertaining to the crown of a tooth.
The
portion of the human tooth covered by enamel; a dental prosthesis restoring the
function and aesthetics of part or all of the coronal
portion of a natural tooth. Crowns are usually composed of gold, porcelain,
and/or acrylic resin.
An artificial substitute for missing natural teeth. A denture may be
complete, full, or partial.
A specialty area of dentistry that deals with the
diagnosis and treatment of diseases of the pulp chamber and canals of teeth.
The separation and surgical removal of a tooth from its
natural position.
A topical application of a fluoride solution to the teeth
to protect against decay.
An unerupted, or partially erupted, tooth that is
positioned against another tooth, bone, or soft tissue, thereby preventing
complete eruption – emergence through the gum.
An insert into bone to support a crown or crowns; a
partial or complete denture.
A
filling made outside the mouth, inserted in the tooth as one piece and secured
with cement.
Inside the mouth.
A restoration that replaces a cusp or cusps of the tooth.
Instruction on the proper care of teeth and gum tissue.
Treatment such as braces to correct position or alignment
of teeth.
Intended
to relieve pain but will not cure the condition.
An x-ray film that shows the curve of both dental arches
and all corresponding teeth; a full mouth x-ray.
An
artificial device, either fixed or removable, that replaces one or more, but
less than all the natural teeth and associated structures supported by the
teeth.
Treatment for diseases of the mouth and gum tissue.
A
false tooth used within a dental bridge.
A
procedure removing plaque, calcium, and stains from tooth surfaces by scaling
and polishing techniques; cleaning.
Replacement of teeth with an appliance such as dentures
or bridges.
The process of refitting a denture by replacing the
denture base material.
Protective
covering applied to the occlusal, biting or grinding, surfaces of permanent
bicuspids and molars to prevent decay.
A
fixed or removable appliance designed to preserve the space created by the
premature loss of a tooth.
The connecting hinge mechanism between the mandible,
lower jaw, and the base of the skull, temporal bone.
A
layer of tooth-colored material, usually porcelain or acrylic resin, that is attached to the surface of a crown or pontic
by direct fusion, cementation, or mechanical retention.