The Penn Faculty Practice Dental Plan for
UPHS Employees

Plan Document and Summary Plan Description

Effective July 1, 2006

Document Outline:
Introduction
1. Eligibility
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 Emergencies
3.2.1 Out-of-the-Area Emergency Care
3.3 Limitations and Exclusions
4. Cost of Coverage
4.1 Employee Contribution
5. Termination of Coverage
5.1 Extension of Benefits
6. Subscriber Responsibilities
7. Coordination with Other Plans
8. Statement of Rights of the University
9. Resolution of Questions Regarding Services
10. Miscellaneous Information

Introduction
The Penn Faculty Practice Dental Plan for University of Pennsylvania Health System Employees (the "Penn Dental Plan") is a program of comprehensive dental benefits with the Penn Dental Care Network, a group of practitioners affiliated with the University of Pennsylvania School of Dental Medicine. All covered services are performed by members of the Penn Dental Care Network.

This document describes the benefits available under the Penn Dental Plan. The Penn Dental Plan is one dental coverage option that is offered through the Health and Welfare Plan of the University of Pennsylvania Health System (the "Health and Welfare Plan"). For more information regarding the Health and Welfare Plan, including eligibility information and important legal information regarding the Health and Welfare Plan and your rights under federal law, employees are encouraged to review the summary plan description (SPD) for the Health and Welfare Plan or to contact the Employee Benefits Office.

1. Eligibility
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 Plan. For a more complete description of the Health and Welfare Plan’s eligibility rules, employees should refer to their enrollment materials or the SPD for the Health and Welfare Plan.

2. Enrollment in the Penn Dental Plan
Eligible UPHS employees may elect the Penn Dental Plan coverage option 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.

2.1 Effective Date of Coverage
For information regarding the effective date of coverage under the Health and Welfare Plan, employees should refer to their enrollment materials or the SPD for the Health and Welfare Plan.

2.2 Mid-Year Election Changes
Eligible employees are permitted to add or drop themselves and/or their dependents from coverage under the Penn Dental Plan on account of certain events (such as birth, adoption or marriage, etc.), provided notice is provided to the Benefits Office 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.

3. Schedule of Benefits
The Penn Dental Plan provides the following coverage:

• Type I Services - 100% Coverage
  Includes routine examinations, cleanings (limited to not more than two times in a 12-month period) radiographs, fluoride applications, sealants, and other diagnostic services. Also includes basic restorative fillings, and extractions. The Penn Dental Plan benefit for a composite (tooth colored) restoration on a bicuspid or molar is based on the alternative benefit of an amalgam (silver) restoration. The difference in charge is the patient’s responsibility.
  
  
• Type II Services - 80% Coverage
  Periodontics, including subgingival curettage, root planing and scaling, periodontal maintenance and surgical periodontics. Endodontics, including pulp treatment, root canal therapy and apicoectomy.
  
  
• Type III Services - 50% Coverage
  Includes inlays, onlays, crowns, bridges, dentures, and space maintainers (prosthetic devices used in children to maintain the gap created by a missing tooth until the permanent tooth emerges).
  
  
• Type IV - 50% Coverage
  Includes one orthodontic treatment per lifetime for children under the age of 19. Indications for orthodontics are an overbite of at least four millimeters, a crossbite, or protrusive or retrusive relationship of at least one cusp. Transfer of patients under treatment will be subject to a monthly treatment fee, which will be covered at the 50% level. Patients in treatment when their Penn Dental Plan coverage is no longer in effect will have their orthodontic benefit prorated according to the amount of time remaining in treatment, a $2,000 lifetime maximum benefit.

3.1 Copayments and Deductibles
For Type II, Type III and Type IV services, there is a $50 deductible that applies. The maximum deductible per individual, per year is $50 or $150 per family. Endodontic and periodontic services are covered at 80%. Copayments are dependent on the type of services provided. For specific copayments, contact your PFP office.

3.2 Emergencies
Emergency care is provided for patients of the Penn Dental Care Network 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.

3.2.1 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 Penn Dental 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 Dental Care Network in order to be covered.

To receive reimbursement from the Penn Dental Plan for palliative treatment, 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 Penn Dental Plan's regular benefit percentages for the service, based on the fees of the Penn Dental Care Network. The subscriber is responsible for any fees in excess of those charged by the Penn Dental Care Network.

3.3 Limitations and Exclusions
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 work in progress on the date the coverage is scheduled to be effective. Work in progress is defined as any of the following:

• An appliance, or modification of one, where an impression was made before the patient was covered.
• A crown, bridge, or gold restoration for which the tooth was prepared before the patient was covered.
• Root canal therapy if the pulp chamber was opened before the patient was covered.

Other procedures not covered by the Penn Dental Plan include, but are not limited, to the following:

• Services or supplies not provided by the Penn Dental Care Network, 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 Dental Plan.
• Restoration (bridge, crown, removable denture or implant) of a tooth or teeth missing or extracted prior to enrollment in the Penn Dental Plan. 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.
• Upgrades (change in restoration or prosthetic device from what the patient had when entering the Penn Dental Plan) such as but not limited to a change from a removable appliance to a fixed appliance, change from tooth supported to implant supported appliances. Unserviceable appliances that meet all the other criteria for replacement will be replaced by like appliances. The PFP covered amount may be used as partial payment towards an upgrade, it is the patient’s responsibility to pay the difference.
• 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.
• Implants.
• Crowns or abutments for dental implants.
• Prosthetic superstructure over implants (crowns, bridges, attachments, dentures) if the implant itself was not covered under the Penn Dental Plan.
• Occlusal appliances, including nightguards.
• Procedures necessary to alter the vertical dimensions or to restore occlusion for the purpose of splinting.
• Replacement of an extracted primary tooth by an implant or fixed bridge.
• 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 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.
• Treatment of temporomandibular joint (TMJ) dysfunction.

4. Cost of Coverage
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 work and orthodontics.

4.1 Employee Contribution
Employees should refer to their enrollment materials for information on what, if any, employee contribution is required for coverage under the Penn Dental Plan. Contributions are taken 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.

5. Termination of Coverage
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 Penn Dental Plan may end is set forth in the SPD for the Health and Welfare Plan.

5.1 Extension of Benefits
If coverage under the Penn Dental Plan is terminated for the subscriber or a family member, the protection will be extended to cover work 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.

6. Subscriber Responsibilities
Subscribers to the Penn Dental Plan are expected to:

• Seek all dental care from the Penn Dental Care Network.
• Pay deductibles and their share of covered services.
• Notify the Benefits Office of any changes in status affecting covered dependents.
• Conform to the standards of practice of the Penn Dental Care Network.
• Give at least 24-hours notice for cancellation of appointments. If a subscriber or his/her dependents fail to give advance notice (a minimum of 24 hrs) a letter will be sent notifying the subscriber that future failed or broken (less than 24 hrs) appointments will require a charge. Subscribers are expected to pay this fee before another appointment will be scheduled.
• Notify their provider at their next appointment of any changes in medical history.
• Be present when a minor child is having dental treatment.
• Be on time for all appointments.
• Maintain good dental health habits.

7. Coordination with Other Plans
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 expense covered, at least in part, by one of the "plans." For this purpose, the term "plans" refers 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 patient 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.

8. Statement of Rights of UPHS
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.

9. Resolution of Questions Regarding Services
If a subscriber believes that he/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:
Elaine Koch
Practice Administrator
Penn Dental Center at University City
3401 Market St.
Philadelphia, PA 19104

Any concerns regarding billing, should be directed to:

Debbie Ditomo
Penn Dental Care Network Billing Coordinator
University of Pennsylvania
Patient Billing
711 Lancaster Ave.
Bryn Mawr, PA 19010
610-520-4544

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.

10. Miscellaneous Information

Plan Administrator:
The Associate Vice President
Human Resources
Hospital of the University of Pennsylvania
3400 Spruce Street
Philadelphia, PA 19104
(215) 615-2675

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