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Underwriting Guidelines

The following is a summary of the Underwriting Guidelines that apply to Oxford Benefit ManagementSM (OBM) plans underwritten by UnitedHealthcare Insurance Company and distributed by OBM:

Eligibility Requirements

  • Employees must actively work at least 30 hours per week on a full-time basis to be eligible for this plan.
  • Eligible dependents include spouse and any children from birth through age 26.

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Effective Dates and Renewals

  • Effective dates of coverage can only be the first of each month.
  • Renewal dates will always be the first of the month.
  • If a group terminates and subsequently seeks to reinstate coverage within six months of the termination date, they will be reinstated at the renewal rates previously communicated, adjusted as necessary for plan changes.

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Eligibility Adjustments

Eligibility adjustment requests (including terminations) can be made via the Online Member Maintenance Tool , emailed to obm@ancillary-benefits.com, faxed to 732-676-2655 or submitted to:

Oxford Benefit Management
12 Christopher Way, Suite 104
Eatontown, NJ 07724

New member additions require a signed member enrollment form unless transaction is processed via Online Member Maintenance. If new additions are made via Online Member Maintenance, then the signed enrollment form is to be retained by the employer. Online Member Maintenance also provides the ability to produce Member and Subscriber Listing reports.

Changes to members made to your Oxford medical plan do not transfer to OBM, they must be submitted directly to Oxford Benefit Management.

Note: All requests for additions and terminations of eligibility must be submitted within 60 days of the effective date.

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Participation Requirements

  • Groups enrolling in Contributory plans must have at least 75% of the active eligible employees enrolled, excluding those waived with spousal coverage (not to fall below 50% of all eligible employees).
  • Groups enrolling in Voluntary plans must have at least 2 people enrolling to be eligible for coverage.
  • For orthodontia, an employer group must have a minimum of 10 enrolling employees. Orthodontia benefits are for dependent children only up to the age of 18.

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Employer Contributions

  • All employer groups not enrolled with Oxford or UHC Medical must submit Wage & Tax information when enrolling.
  • The employer must contribute at least 50% towards the employee's premium for Contributory plans and no more than 49% for Voluntary plans.

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Excluded Industries

  • Most industries are eligible for coverage.
  • Private households and husband/wife groups are not eligible.

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Waiting Periods for New and Takeover Plans

The following waiting periods apply for all groups sized 2-99 lives for major and orthodontic services in the OBMSM Preferred Specialty Option, OBMSM Voluntary Specialty Option, OBMSM Elite Specialty Option, OBMSM Incentive Specialty Option and OBMSM Premier Specialty Option.

New York
Major Services 6 months
Orthodontia Services 6 months

New Jersey and Connecticut
Major Services 12 months
Orthodontia Services 12 months

For an additional charge, benefit waiting periods for new and takeover plans may be waived for existing employees and future hires. This charge will apply for life of case. (Not available for Basic or Voluntary plans).

Takeover benefits from a prior carrier

  • The waiting period limitations will be waived if an insured was continuously covered under the group's prior insured dental plan for the same services within the same period of time as above. The employer group would need to supply a prior carrier bill, as well as a Summary of Benefits document. For example, if a group had 12 months of prior coverage that included major and orthodontic services, the waiting period for all employees at the initial effective date will be waived. Any new hires or late entrants would be subject to the waiting periods above.
  • Employees enrolled under the prior dental carrier's plan will receive deductible credit towards the new plan's deductible. Benefits paid from the prior carrier will be deducted from the maximum during the first plan year.

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Late Entrants

  • A late entrant is any person who becomes insured more than 31 days after he or she is eligible or becomes insured again after his or her insurance ended due to non-payment of premium.
  • Once a late entrant becomes insured, the plan will pay for covered preventive and basic services immediately; however, the plan will pay for covered major and orthodontic services after 12 months for Connecticut and New Jersey groups and after 6 months for New York groups. These waiting periods will be waived if eligible employees or dependents that initially waived coverage because they had coverage elsewhere now enroll because that coverage has terminated. Proof of prior coverage must accompany the UnitedHealthcare Dental and Vision Member Enrollment Forms.

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Pretreatment Review

If a dental examination reveals that treatment is expected to exceed $200, the dentist must notify Unitedhealthcare Dental, via claim form, within 20 days of the exam. If requested, the dentist must provide dental x-rays, study models or other information necessary to evaluate the treatment plan for purposes of benefit determination.

UnitedHealthcare will decide if the proposed treatment is covered under the policy and estimate the amount of payment. The estimate of benefits payable will be sent to the dentist and will be subject to all terms, conditions and provisions of the policy. If a treatment plan is not submitted, the covered person will be responsible for payment of any dental treatment not approved by Unitedhealthcare . Clinical situations that cannot be effectively treated by a less costly, clinically acceptable alternative procedure will be assigned a benefit based on the less costly procedure.

Pretreatment review of benefits is not an agreement to pay for expenses. This review lets the covered person know in advance approximately what portion of the expenses will be considered for payment. No benefits will be paid for a dental service that has not begun within 90 days after the treatment plan notice is sent to Unitedhealthcare Dental.

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Covered Dental Services

Dental Services described in this section are covered when such services are:

A. Necessary;
B. Provided by or under the direction of a dentist or other appropriate provider, as specifically described;
C. The least costly, clinically accepted treatment; and
D. Not excluded as described in the Section entitled, Exclusions and Limitations on Insured Dental Plans.

Network Benefits are subject to satisfaction of the Annual Deductible, applicable waiting periods and payment of the percentage of Eligible Expenses listed under the "Network Copayment" column in the Schedule of Benefits. Covered Dental Services must be provided by or directed by a Network Dentist.

Non-Network Benefits are subject to satisfaction of the Annual Deductible, applicable waiting periods and payment of the percentage of Eligible Expenses listed under the "Non-Network Copayment" column in the Schedule of Benefits.

COVERED SERVICES

BENEFIT GUIDELINES

PREVENTIVE DENTAL SERVICES

   

Periodic Oral Examinations

Limited to 2 times per consecutive 12 months

Bite-Wing X-rays

One series of films per calendar year.

Complete Series or Panorex X-rays

Limited to one time per consecutive 36 months.

Dental Prophylaxis (Cleanings)

Limited to 2 times per consecutive 12 months.

Fluoride Treatments

Limited to covered persons under the age of 16 years, and limited to 2 times per consecutive 12 months.

Sealants

Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.

BASIC DENTAL SERVICES

Space Maintainers

For covered persons under the age of 16 years, once per lifetime.

Palliative Treatment (Relief of Pain)

Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.

General Anesthesia

When medically necessary.

Amalgam Restorations (Fillings)

Multiple restorations on one surface will be treated as a single filling.

Composite Restorations (Fillings)

Multiple restorations on one surface will be treated as a single filling. For anterior teeth only.

Simple Extraction

Surgical Extraction including Impacted Wisdom Teeth

Root Canal Treatment

Scaling and Root Planing

Limited to one time per quadrant per consecutive 24 months.

Periodontal Surgery

Limited to once every consecutive 36 months per surgical area.

Periodontal Maintenance

Limited to 2 times per consecutive 12 months following active and adjunctive periodontal therapy within the prior 24 months, exclusive of gross debridement.

MAJOR DENTAL SERVICES

Crowns, Inlays, and Onlays

Limited to one time per tooth per consecutive 60 months.

Fixed Bridges

Once per tooth per consecutive 60 months. Alternate benefits for a partial denture may be applied.

Full Dentures

Once per consecutive 60 months. No allowance for overdentures or customized dentures.

Partial Dentures

Once per consecutive 60 months. No allowance for precision or semi-precision attachments.

Recement Bridges, Crowns, Inlays

Relining and Rebasing Dentures

Limited to one time every consecutive 12 months, and limited to relining done more than 6 months after the initial insertions.

Repairs to Full Dentures, Partial Dentures, Bridges

Limited to repairs or adjustments performed more than 12 months after the initial insertion.

Please Note: Refer to the dental certificate for a comprehensive list of all exclusions, terms and conditions which may affect a covered persons benefits under the product to the extent there is a conflict between the information noted in this material and the covered person's certificate, the certificate shall prevail.

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Exclusions

The following are not covered:

  1. Dental Services that are not necessary.
  2. Hospitalization or other facility charges.
  3. Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance).
  4. Reconstructive Surgery regardless of whether or not the surgery which is incidental to a dental disease, injury, or Congenital Anomaly when the primary purpose is to improve physiological functioning of the involved part of the body.
  5. Any dental procedure not directly associated with dental disease.
  6. Any procedure not performed in a dental setting.
  7. Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.
  8. Services for injuries or conditions covered by Worker's Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.
  9. Expenses for dental procedures begun prior to the Covered Person's eligibility with the Plan.
  10. Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates.
  11. Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child.
  12. Dental Services provided in a foreign country, unless required as an Emergency.
  13. Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to plan coverage unless the patient has been eligible under the plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12 month period, the plan is responsible only for the procedures associated with the addition.
  14. Replacement of missing natural teeth lost prior to the onset of plan coverage until the patient has been eligible for 12 continuous months.
  15. Replacement of complete or partial dentures, crowns, or fixed bridgework if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.
  16. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.
  17. Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.
  18. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).
  19. Placement of dental implants, implantsupported abutments and prostheses. This includes pharmacological regimens and restorative materials not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.
  20. Placement of fixed bridgework solely for the purpose of achieving periodontal stability.
  21. Billing for incision and drainage if the involved abscessed tooth is removed on the same date of service.
  22. Treatment of malignant or benign neoplasms, cysts, or other pathology, except excisional removal. Treatment of congenital malformations of hard or soft tissue, including excision.
  23. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
  24. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.
  25. Acupuncture; acupressure and other forms of alternative treatment.
  26. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
  27. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

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LIMITATIONS

Oral Examinations: Covered as a separate benefit only if no other service was performed during the visit other than prophylaxis and X-rays. Limited to 2 times per consecutive 12 months.

Complete Series or Panorex Radiographs: Limited to one time per consecutive 36 months. Exception to this limit will be made for Panorex Radiographs if taken for diagnosis of third molars, cysts, or neoplasms.

Bitewing Radiographs: Limited to 1 series of films per calendar year.

Extraoral Radiographs: Limited to 2 films per calendar year.

Dental Prophylaxis: Limited to 2 times per consecutive 12 months.

Diagnostic Casts: Limited to one time per consecutive 24 months.

Fluoride Treatments: Limited to covered persons under the age of 16 years, and limited to 2 times per consecutive 12 months. Treatment should be done in conjunction with dental prophylaxis.

Sealants: Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.

Space Maintainers: Limited to covered persons under the age of 16 years, once per lifetime. Benefit includes all adjustment within 6 months of installation.

Restorations: Multiple restorations on one surface will be treated as a single filling. Composite restorations limited to anterior teeth only.

Pin Retention: Limited to 2 pins per tooth; not covered in addition to Cast Restoration.

Inlays and Onlays: Limited to one time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

Crowns: Limited to one time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

Post and Cores: Covered only for teeth that have had root canal therapy.

Sedative Fillings: Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.

Scaling and Root Planing: Limited to 1 time per quadrant per consecutive 24 months.

Periodontal Maintenance: Limited to 2 times per consecutive 12 months following active and adjunctive periodontal therapy within the prior 24 months, exclusive of gross debridement.

Full Dentures: Limited to once every consecutive 60 months. No additional allowances for overdentures or customized dentures.

Partial Dentures: Limited to once every consecutive 60 months. No additional allowances for precision or semi-precision attachments.

Relining and Rebasing Dentures: Limited to relining or rebasing performed more than 6 months after the initial insertions. Limited to 1 time per consecutive 12 months.

Repairs to Full Dentures, Partial Dentures, Bridges: Limited to repairs or adjustments performed more than 12 months after the initial insertion.

Palliative Treatment: Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.

Occlusal Guards: Covered only if prescribed to control habitual grinding, and limited to one guard every consecutive 36 months.

Full Mouth Debridement: Limited to once every consecutive 36 months.

General Anesthesia: Covered only where medically necessary.

Osseous Grafts: With or without resorbable GTR membrane replacement, are limited to once every consecutive 36 months per quadrant or surgical site.

Periodontal Surgery: Hard tissue and soft tissue periodontal surgery are limited to once every consecutive 36 months, per surgical area. This includes gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, pedicle grafts, and free soft tissue grafts.

Replacement Of Full Dentures, Partial Dentures, Bridges or Crowns: Replacement of complete or partial dentures, both fixed and removable, or crowns, previously submitted for payment under this Plan is limited to once every consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.

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Vision Exclusions & Limitations

The following services and materials are excluded from coverage under the vision policy:

  • Post cataract lenses.
  • Non-prescription lenses.
  • Medical or surgical treatment for eye disease, that requires the services of a physician.
  • Worker's compensation services or materials.
  • Services or material that the patient, without cost, obtains from any governmental organization or program.
  • Services or materials that are not specifically covered by the policy.
  • Replacement or repair of lenses and/or frames that have been lost of broken.
  • Cosmetic extras, except as stated in the vision policy's table of benefits.

Please Note: Refer to the vision certificate for a comprehensive list of all exclusions, terms and conditions which may affect a covered persons benefits under the product to the extent there is a conflict between the information noted in this material and the covered person's certificate, the certificate shall prevail.

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