The Penn Faculty Practice Dental Plan for University Retirees
Plan Document and Summary Plan Description

Document Outline

Introduction
1. Eligibility
1.1 Changes in Family Status
2. Enrollment in the Plan
2.1 Effective Date of Coverage
3. Schedule of Benefits
3.1 Emergencies
3.1.1 Out-of-Area Emergency Care
3.2 Limitations and Exclusions
4. Cost of Coverage
4.1 Premiums
4.2 Copayments
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

Introduction

The Penn Faculty Practice Dental Plan for University Retirees is a program of comprehensive dental coverage with the Penn Faculty Practice, 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:

1. Eligibility
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:

· Spouses

· Same-sex domestic partners that meet the requirements for same-sex partners as set forth in University policy and as designated by the employee on a form provided by the Benefits office

· Unmarried dependent children under the age of 19

· Full-time college students under the age of 23

· Unmarried stepchildren, foster children, and legally adopted children under the age of 19 who depend upon the employee for support and maintenance

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.

1.1 Changes in Family Status
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.

2. Enrollment in the Plan
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.

2.1 Effective Date of Coverage
The effective date of coverage under the Plan will be the first day of the month following enrollment.

3. Schedule of Benefits
The Penn Faculty Practice Dental Plan for University Retirees provides the following coverage:

· Type I Services - 100% Coverage
Diagnostic, including routine examinations and consultations and radiographs (x-rays).

Preventive, including fluoride applications; prophylaxis; oral hygiene counseling; and nutritional counseling.

Simple Restorations, including amalgam and tooth-colored fillings.

Oral Surgery (out of hospital only), including extractions; incision and drainage of abscesses; alveolectomy and alveoplasty; removal of oral cysts and tumors; and other routine oral surgical procedures performed in the office.

Emergency Treatment, including palliative treatment for the relief of pain or discomfort.

· Type II Services - 60% Coverage
Periodontics, including subgingival curettage, root planing, and scaling; surgical periodontics; and occlusal adjustment.

Endodontics, including pulp treatment; root canal therapy; and apicoectomy.

Space Maintainers (prosthetic devices used in children to maintain the gap created by a missing tooth until the permanent tooth emerges).

· Type III Services - 50% Coverage
Major Restorations, including inlays, crowns (when determined by the dentist to be necessary), and bridges.

Dentures, including complete upper or lower dentures; partial dentures; and relining and repair of dentures requiring laboratory work.

Repairs and Adjustments, including recementation of inlays, crowns, and bridges; and relining and repair of dentures not requiring laboratory work.

There is an annual max of $1,000 per plan year.

3.1 Emergencies
Emergency care is provided for patients of the Penn Faculty Practice on a 24-hour basis. If an emergency occurs outside of normal business hours, the subscriber should call (215) 898-4615 or any Network office for a referral to the provider on call.

3.1.1 Out-of-the-Area Emergency Care
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 Faculty Practice. The subscriber is responsible for any fees in excess of those charged by the Penn Faculty Practice.

3.2 Limitations and Exclusions
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:

• Services or supplies not provided by the Penn Faculty Practice, except those required for emergency care outside of the area
• Services provided under any government program or law under which the individual is, or could be, covered, as determined by the Penn Faculty Practice Dental Plan
• Restoration (bridge, crown, removable denture or implant) of a tooth or teeth missing or extracted prior to enrollment in a dental insurance plan sponsored by the University of Pennsylvania. If the extraction was not performed by a University of Pennsylvania Dental Care Network office, the patient is responsible for obtaining documentation of the extraction's age.
• Replacement or upgrade of a previous restoration (bridge, crown, removable denture or implant) that is less than 60 months old. If the restoration was not performed by a University of Pennsylvania Dental Care Network office, the patient is responsible for obtaining documentation of the restoration's age.
• Abutments for dental implants
• Prosthetic superstructure over implants (crowns, bridges, attachments, dentures) if the implant itself was not covered under the Plan.
• Occlusal appliances, including nightguards
• Procedures necessary to alter the vertical dimensions or to restore occlusion for the purpose of splinting
• Splinting teeth with permanent restorations (crowns) for periodontal purposes
• Services necessitated by an accident related to employment or disease covered under the workers’ compensation or similar law
• Replacement of lost or broken orthodontic appliances
• Oral surgery and related expenses in a hospital
• Any dentistry requiring hospitalization
• General Anesthesia - conscious (IV or Oral ) sedation - for basic dentistry services (i.e. fillings, extractions). For complex extractions, the Penn Faculty Practice Dental Plan Office will work with your primary health insurance for coverage.
• Dentistry primarily for cosmetic purposes
• A service provided while the patient’s coverage is not in effect, except as provided under Section 5.1

If an individual age 5 or more is not enrolled after the end of the 30-day period allowed for addition of a new dependent, there will be a 12-month waiting period for all Type II, III, and IV services. This does not apply to services resulting from accidental injury during the waiting period.

4. Cost of Coverage

4.1 Premiums
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.

4.2 Copayments
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.

5. Termination of Coverage
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.

5.1 Extension of Benefits
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.

5.2 Death of Retiree
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.

6. Subscriber Responsibilities
Subscribers to the Penn Faculty Practice Dental Plan for University Retirees are expected to

• Seek all dental care from the Penn Faculty Practice
• Pay their monthly premium by the requested due date
• Pay their share of covered services
• Notify the Plan of any changes in family status affecting covered dependents
• Conform to the standards of practice of the Penn Faculty Practice
• Give at least 24 hours' notice for cancellation of appointments
• Be on time for all appointments
• Maintain good dental health habits

7. Coordination With Other Plans
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.

8. Statement of Rights of the University
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.

9. Statement of Your Rights Under ERISA
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:

· Examine, without charge, at the Benefits office and at other specified locations, all Plan documents and copies of all documents filed by the Plan with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions.

· Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator, who may make a reasonable charge for the copies.

· Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each subscriber with a copy of this summary annual report.

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.

10. Resolution of Questions Regarding Services
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:

· The specific reason or reasons for the denial;

· Specific reference to the Penn Faculty Practice Dental Plan provisions on which the denial is based;

· A description of any additional material needed so that a benefit may be paid or the service provided and an explanation of why such material or information is necessary; and

· An explanation of the claim review procedure set forth below.

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.

11. Miscellaneous Information
Name of Plan:
The Penn Faculty Practice Dental Plan for University Retirees

Employee/Plan Sponsor:
Trustees of the University of Pennsylvania
3401 Walnut Street
Philadelphia, PA 19104

Employer IRS Identification Number:
23-1352685

Plan Number:
529

Type of Plan:
Welfare Benefit Plan (Dental Benefits)

Billing Coordinator:
Donna Mieciecki
University of Pennsylvania
Patient Billing
711 Lancaster Ave
Bryn Mawr, PA 19010
610-520-4544

Agent for Service of Legal Process:
Penn Faculty Practice Dental Plan Office
University of Pennsylvania
School of Dental Medicine

Plan Year:
The Plan year begins each July 1 and ends each June 30.