Effective July 1, 2013
2. Enrollment in the Penn Dental Plan
2.1 Effective Date of Coverage
2.2 Mid-Year Election Changes
3. Schedule of Benefits
3.1 Copayments and Deductibles
3.2.1 Out-of-the-Area Emergency Care
3.3 Limitations and Exclustions
4. Cost of Coverage
4.1 Employee Contribution
5. Termination of Coverage
5.1 Extension of Benefits
6. Subscriber Responsibilities
7. Changes in Family Status
8. Coordination with Other Plans
9. Statement of Rights of the University
10. Resolution of Questions Regarding Services
11. Miscellaneous Information
The Penn Faculty Practice Dental Plan of the University of Pennsylvania (“Penn Dental Plan” or “Plan”) is a program of comprehensive dental benefits with the Penn Dental Faculty Practices, a group of oral health professionals affiliated with the University of Pennsylvania School of Dental Medicine. You benefit from a team of experts who not only teach the next generation of dentists, but also practice using the latest techniques in patient care. All covered services are performed by members of Penn Dental Faculty Practices, who provide general and specialty treatment under one roof at three office locations.
This document describes the benefits available under the Penn Dental Plan. The Plan is one dental coverage option that is offered through the University of Pennsylvania Health and Welfare Program (the “Health and Welfare Program”). For more information regarding the Health and Welfare Program, including eligibility information and important legal information regarding the Program and your rights under federal law, employees are encouraged to review the summary plan description (SPD) for the Health and Welfare Program, or contact the Employee Benefits Office.
The Penn Dental Plan is open to employees (and their eligible dependents) of the University of Pennsylvania Health System who satisfy the eligibility requirements for participating in the Health and Welfare Program. For a more complete description of the Health and Welfare Program’s eligibility rules, employees should refer to their enrollment material or the summary plan description (SPD) for the Health and Welfare Program.
Eligible UPHS employees may enroll either upon or during the annual open enrollment period. Eligible new employees may enroll upon hire. With the exception of certain mid-year election changes described in Section 2.2, eligible dependents may be added to coverage only at the time that the employee enrolls or during an open enrollment period.
For information regarding the effective date of coverage under the Health and Welfare Program, employees should refer to their enrollment materials of the SPD from the Health and Welfare Program.
Eligible employees are permitted to add or drop themselves and/or their eligible dependents from coverage under the Penn Dental Plan on account of certain events (such as birth, adoption, marriage, etc.) provided that notice is given to the Benefits Office and the Penn Dental Faculty Practices within 30 days of the event. More information about change in status events can be found in the SPD for the Health and Welfare Plan.
The Penn Dental Plan provides the following coverage:
Please refer to the limitations and exclusions section.
The orthodontic benefit will be applied towards the annual maximum Plan benefit of $3,000.
For Type II, III, and IV services, there is a $50 Plan year (July 1-June 30) deductible that applies. The maximum deductible per individual per year is $50 or $150 per family. Copayments are dependent on the type of services provided and are due at the time of treatment. For specific copayments, contact your Penn Dental Faculty Plan office.
Emergency care is provided for subscribers of 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 Practice office for a referral to the emergency provider on call.
In the event that an emergency occurs when the subscriber is more than 100 miles away from one of the Faculty Practices, palliative treatment (treatment to alleviate the immediate discomfort) from a non-plan dentist is covered by the Penn Dental Plan. Examples of emergencies are pain, fever, swelling, bleeding, or loss of a tooth.
Treatment from a non-plan dentist should be limited to palliative treatment. Follow-up care must be provided by Penn Dental Faculty Practices in order to be covered.
To receive reimbursement from the Penn Dental Plan for palliative treatment, the subscriber must submit an itemized bill with procedure codes and receipt of payment from the dentist who provided the emergency treatment. If x-rays were taken, they must also be included or forwarded electronically.
The subscriber is responsible for all out of pocket expenses incurred for the emergency care treatment. The subscriber shall receive reimbursement from the Penn Dental Plan for the palliative emergency services at a rate equal to the Penn Dental Faculty Practice fee for the same or similar service, subject to the Plan coverage and limitations. The subscriber is responsible for any fees charged by the dentist who provided emergency treatment that are in excess of those charged by Penn Dental Faculty Practices.
The maximum annual benefit per plan year (July 1-June 30) for each family member is $3,000.
The Penn Dental Plan will NOT cover:
Other procedures not covered by the Penn Dental Plan include, but are not limited to, the following:
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 billing staff for individual payment plans, such as those for crown and bridge treatment and orthodontics.
Employees should refer to their enrollment materials for information on what, if any, employee contribution is required for coverage under the Penn Faculty Plan. Contributions are deducted from pay before any federal income tax, FICA (Social Security) tax and Medicare Insurance tax are withheld. The state tax treatment will differ from state to state. There are exceptions to the pre-tax status of your contributions for a same-sex partner and a partner’s child(ren) who are not your tax dependents. See the SPD for the Health and Welfare Plan for more information about these special situations.
In general, coverage for the subscriber and family members will terminate if the subscriber ceases to be an eligible employee of the University of Pennsylvania Health System or if the Penn Dental Plan is discontinued by the University of Pennsylvania Health System. More detailed information about when and how coverage under the Dental Faculty Plan may end is set forth in the SPD for the Health and Welfare Plan.
If coverage under the Penn Dental Plan is terminated for the subscriber or a family member, the protection will be extended to cover treatment in progress or basic services received within the next 30 days provided that these services would have been covered had the Penn Dental Plan remained in effect. Payment for treatment received after this extension period will be on a fee-for-service basis.
Subscribers to the Penn Dental Plan are expected to:
Notify the Benefits Office of any changes in family status affecting covered dependents.
The Penn Dental Plan contains a provision that coordinates the benefits it pays on behalf of an individual with payments that may be made under other plans covering the individual so that the total benefits available will not exceed 100% of the allowable expenses.
An allowable expense is any necessary, reasonable, and customary expenses covered, at least in part, by one of the “plans.” For this purpose, the terms “plans” refer to the following types of medical and dental care benefit programs: (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. The Penn Dental Plan will not pay more than it would have paid if there was no other plan. A plan without a coordination provision is always the primary plan. If all plans have a coordination provision, the plan covering the subscriber directly, rather than as a dependent, is the primary plan. If both parents cover a dependent child, except for situations where the parents 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 that covered the parent longer shall be primary.
As with any other coverage option provided under the Health and Welfare Plan, UPHS (acting through its Executive Committee or a duly authorized delegate) reserves the right to amend or terminate the Penn Dental Plan, in whole or in part, at any time
If a subscriber believes that he or she has not been provided with sufficient information about the Penn Dental Plan or has been denied a benefit under the Penn Dental Plan, the subscriber may file a written claim with:
Penn Dental Center at University City
3401 Market St.
Philadelphia, PA 19104
Detailed information about filing claims and appealing denied claims for benefits under the Penn Dental Plan is set forth in the SPD for the Health and Welfare Plan.
The Associate Vice President
Hospital of the University of Pennsylvania
3400 Spruce Street
Philadelphia, PA 19104
The Plan year begins each July 1st and ends June 30th.