1.1 Changes in Family Status
2. Enrollment in the Plan
2.1 Effective Date of Coverage
3. Schedule of Benefits
3.1.1 Out-of-Area Emergency Care
3.2 Limitations and Exclusions
4. Cost of Coverage
5. Termination of Coverage
5.1 Extension of Benefits
5.2 Death of Retiree
6. Subscriber Responsibilities
7. Coordination With Other Plans
8. Statement of Rights of theUniversity
9. Statement of Your Rights Under ERISA
10. Resolution of Questions RegardingServices
11. Miscellaneous Information
The Penn Faculty Practice Dental Plan for University Retirees is a program of comprehensive dental coverage with the Penn Dental Faculty Practices, a group of practitioners affiliated with the University of Pennsylvania School of Dental Medicine. All covered services are performed by members of the Practice at the following locations:
Penn Dental at the Robert Schattner Center
Penn Dental Center at Bryn Mawr
Penn Dental Center at University City
The Penn Faculty Practice Dental Plan for University Retirees is open only to retired Penn faculty and staff who were covered by COBRA as of 6/30/05. Eligible retirees who enroll in the Plan also have the option to enroll dependents. Eligible dependents include:
A child who is physically or mentally incapable of self-support upon attaining age 19 may be continued under the Plan while remaining incapacitated and unmarried, subject to continuation of the employee’s own coverage. Proof of incapacity must be received by the Benefits office within 30 days after coverage would otherwise terminate. Additional proof may be required from time to time.
When two family members are eligible for the Plan, both may enroll as subscribers but only one may elect family coverage.
Subscribers in the Penn Faculty Practice Dental Plan for University Retirees must notify the Benefits office within 30 days in the event that a new family member becomes eligible through birth, adoption, or marriage. A 12-month waiting period for certain services will apply to dependents over the age of 5 who are added to coverage after the end of this 30-day period (see Section 3.2, Limitations and Exclusions). Subscribers are also required to notify the Benefits office when a covered family member is no longer eligible, for example when a child is over the age of 19 or when a child’s dependency status changes through marriage.
University retirees must enroll in the Plan within 30 days of the termination of dental coverage being purchased under the provisions of the Consolidated Omnibus Reconciliation Act of 1986 (COBRA). Retirees are not be permitted to enroll in the Plan outside of this time period.
Dependents must be enrolled at the same time as the University retiree. No dependents can be added on to the coverage at a later date, with the exception of the addition of new family members as described Section 1.1, Changes in Family Status.
The effective date of coverage under the Plan will be the first day of the month following enrollment.
The Penn Faculty Practice Dental Plan for University Retirees provides the following coverage:
There is an annual max of $1,000 per plan year.
Emergency care is provided for patients of the Penn Dental Faculty Practices on a 24-hour basis. If an emergency occurs outside of normal business hours, the subscriber should call (215) 898-4615 or any Penn Dental Faculty Practices office for a referral to the provider on call.
In the event that an emergency occurs when the subscriber is more than 50 miles away, palliative treatment (treatment to alleviate the immediate discomfort) from a non-plan dentist is covered by the Plan. Examples of emergencies are pain, fever, swelling, bleeding, severe discomfort, or loss of a tooth.
Treatment from a non-plan dentist should be limited to palliative treatment. Follow-up care must be provided by the Penn Faculty Practice in order to be covered.
To receive reimbursement from the Penn Faculty Practice Dental Plan, the subscriber must submit an itemized bill with a diagnosis and receipt of payment from the dentist who provided emergency treatment. If x-rays were taken, they should also be included.
The dentist’s bill will be reimbursed to the subscriber at the Plan’s regular benefit percentages for the service, based on the fees of the Penn Dental Faculty Practices. The subscriber is responsible for any fees in excess of those charged by the Penn Dental Faculty Practices.
There is a limit of 2 cleanings per year.
The Plan will not cover work in progress on the date the coverage is scheduled to be effective. Work in progress is defined as any of the following:
Other procedures not covered by the Plan include, but are not limited, to the following:
The subscriber will be billed a monthly premium for coverage in the Plan. Payments are to be mailed to the Penn Faculty Practice Dental Plan Office.
The monthly rates for individual and family coverage are based on the recommendations of an independent actuarial firm. Current premiums are are available at http://www.hr.upenn.edu. These rates are subject to revision on an annual basis.
Subscribers are expected to pay their share of the cost of services, if any, at the time of their visit. Arrangements can be made with the office manager for periodic payment of large lump sum copayments, such as those for crown and bridge work.
Coverage for the retiree and family members will terminate upon request of the subscriber or if the subscriber’s premium payments become delinquent by more than 60 days. Coverage for a dependent will terminate when he or she no longer meets the eligibility criteria described in Section 1, Eligibility. Coverage for the retiree and family members will also terminate upon the termination of the Penn Faculty Practice Dental Plan. Once coverage is terminated, it cannot be reinstated.
If coverage under the Penn Faculty Practice Dental Plan for University Retirees is terminated for you or a family member, the protection will be extended to cover work in progress or Type I services received within the next 30 days provided that these services would have been covered had the Plan remained in effect. Payment for treatment received after this extension period will be on a fee-for-service basis.
In the event of death of the University retiree, coverage under the Plan can be continued for a spouse or other eligible dependent who was covered by the Plan at the time of the retiree’s death.
Subscribers to the Penn Faculty Practice Dental Plan for University Retirees are expected to
The Penn Faculty Practice Dental Plan for University Retirees contains a provision coordinating it with other 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. Plans refers to the following types of medical and dental care benefits: (a) coverage under a government program or coverage 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 through employment or other coverage obtained through an educational institution above the high school level.
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 is always the primary plan. If all plans have a coordinating provision, the plan covering the patient directly, rather than as a dependent, is primary and the others secondary.
Except for situations where the parents of a child are separated or divorced, the plan of the parent whose date of birth (month, day) falls earlier in the calendar year is the primary plan for that child. If both parents have the same birth date, the plan which covered the parent longer shall be primary.
The Board of Trustees of the University reserves the right to amend or terminate the Penn Faculty Practice Dental Plan for University Retirees, in whole or in part, at any time. The University, by action of its Board, also may delegate any of its power and duties with respect to the Penn Faculty Practice Dental Plan for University Retirees or its amendments to one or more officers or other employees of the University.
Subscribers in the Plan are entitled to certain rights and protections under ERISA. ERISA provides that all Plan subscribers shall be entitled, upon reasonable request, to:
In addition to creating rights for Plan members, ERISA imposes duties upon the people, called “fiduciaries,” who are responsible for the operation of the Plan. They have a duty to operate the Plan prudently and in the interest of the Plan subscribers and beneficiaries. The University may not discharge a subscriber or otherwise discriminate against a subscriber in any way to prevent the subscriber from obtaining a benefit or exercising his or her rights under ERISA. If a subscriber’s claim for a benefit is denied in whole or in part, he or she must receive a written explanation of the reason for the denial. A subscriber has the right to have his or her claim reviewed and reconsidered.
Under ERISA, there are steps a subscriber can take to enforce the above rights. For instance, a subscriber may file suit in a federal court if he or she requests materials from the Plan and does not receive them within 30 days. The court may require the Plan Administrator to provide the materials and pay the subscriber up to $100 a day until the subscriber receives them (unless the materials were not sent because of reasons beyond the Plan Administrator’s control). If a subscriber’s claim for benefits or services is denied in whole or in part, or ignored, the subscriber may file suit in a state or federal court. If a subscriber believes Plan fiduciaries have misused the Plan’s money, or have discriminated against the subscriber for asserting his or her rights, the subscriber may seek assistance from the U.S. Department of Labor or file suit in a federal court. If the subscriber is successful, the court may order the person sued to pay court costs and legal fees. If the subscriber loses, the court may order the subscriber to pay, for example, if it finds his or her claim is frivolous.
If a subscriber has any questions about the Plan, he or she should contact the Plan Administrator. If a subscriber has any questions about this statement or about such subscriber’s rights under ERISA, the subscriber should contact the nearest Area Office of the U.S. Labor Management Services Administration, Department of Labor.
If a subscriber believes that the Plan Administrator has failed to advise him or her about available services under the Penn Faculty Practice Dental Plan or has failed to pay any benefit to which such subscriber is entitled, the subscriber may file a written claim with the Plan Administrator. The Plan Administrator will respond to the claim within a reasonable amount of time. If the subscriber is denied a claim for benefits or services, the Plan Administrator will provide the subscriber with a written notice setting forth in simple terms:
Within 60 days of the date the subscriber receives a notice denying a claim, the subscriber may request (in writing) a full review of the claim by the Plan Administrator setting forth all the facts on which the appeal is based. The Plan Administrator will make a decision promptly, and not later than 60 days after receipt of the request for review, unless special circumstances require an extension of time for processing. In that case, a decision will be rendered as soon as possible, but not later than 120 days after receipt of the request for review. The decision on review will be in writing. The Plan Administrator’s determination shall be binding upon all parties.
Name of Plan:
The Penn Faculty Practice Dental Plan for University Retirees
Trustees of the University of Pennsylvania
3401 Walnut Street
Philadelphia, PA 19104
Employer IRS Identification Number:
Type of Plan:
Welfare Benefit Plan (Dental Benefits)
Agent for Service of Legal Process:
Penn Faculty Practice Dental Plan Office
University of Pennsylvania
School of Dental Medicine
The Plan year begins each July 1 and ends each June 30.