MONROE COMMUNITY COLLEGE
Dental Assistance Plan
Monroe Community College
DENTAL ASSISTANCE PLAN
TABLE OF CONTENTS
Introduction.................................................................................3
Eligibility ....................................................................................4
Your Dentist................................................................................4
Definitions ..................................................................................5
Services & Plan Benefits ............................................................6
Covered Dental Services .............................................................6
Benefits for Covered Dental Expenses .......................................7
Annual Maximum .......................................................................8
Pre-Treatment Estimates .............................................................8
Coordination of Benefits.............................................................9
Claims Administration ................................................................9
Specific Limitations ..................................................................11
General Limitations ..................................................................12
Termination of Benefits ............................................................13
COBRA.....................................................................................13
Claims Review Procedure.........................................................15
Administration ..........................................................................16
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INTRODUCTION
Your Dental Assistance Plan is designed to encourage good dental
health for employees and their family members while helping
them meet the expenses of quality dental care. Regular check-ups
(at least once every year) and prompt treatment of small problems
when they are first discovered combine to help prevent more
serious problems from developing later.
The Plan allows employees and their dependents complete
freedom in the choice of a dentist, and the Plan places virtually no
restriction on the dentist as to the type of care or treatment
undertaken to assure the patient’s dental health.
For you, the employee, and for your dependents, there are no
preliminary dental examination requirements to establish
eligibility. For your dentist, there is a minimum of paperwork.
If you have any questions about your Plan after reading this
booklet, please contact your Human Resources Department or
Health Economics Group.
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ELIGIBILITY
All active full-time participating employees hired on or before the
fifteenth day of the month are eligible for the Monroe Community
College Dental Assistance Plan from the first day of the month.
All active full-time participating employees hired after the
fifteenth day of the month are eligible for the Monroe Community
College Dental Assistance Plan on the first of the month which
falls after the end of the hire month PLUS one month.
Your dependents are also eligible as follows:

Your spouse.

Your children, including stepchildren and legally adopted
children and children who have been placed under your
legal guardianship, if they are under 19 years of age,
unmarried or are under age 23 years of age and are full-time
students and unmarried.
Unmarried children will continue to be covered after age 19 if
incapable of self-sustaining employment by reason of mental or
physical handicap.
No person may be covered by the Plan as both an employee and a
dependent nor as the dependent of more than one person.
YOUR DENTIST
You and your eligible dependents have free choice of any legally
practicing dentist. Monroe Community College does not intend to
disturb the dentist-patient relationship and will not, under ordinary
circumstances, interfere with the free exercise of professional
judgment by the dentist as to the care provided. The science and
practice of dentistry are evolving, however, and occasionally
differences of opinion arise. In cases of dispute, Monroe
Community College will rely on the findings of the Plan
Manager’s Dental Advisor and upon applicable Peer Review
organizations.
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Most dentists look upon Dental Assistance Plans with favor
because they know these plans encourage good dentistry. You
should discuss your Plan with your dentist and go over points in
this descriptive booklet. Ask for clarification as necessary. This
will help you understand your Plan and how it can assist you to
reach and maintain good oral health.
DEFINITIONS
Dentist – A dentist is an individual licensed to practice dentistry
and/or to perform oral surgery. A licensed physician
who performs dental services within the scope of a
medical license will also be considered to be a dentist
for the purposes of this Plan.
Usual, Customary and Reasonable Charges (UCR) – The fee
charged for a dental service will be considered:
Usual:
If it is what the dentist most commonly charges his
or her patients whether or not they are covered by a
dental plan,
Customary: If it is within the range of amounts charged by
Dentists in the locality where the service is
rendered, and
Reasonable: If the fee is justified by any special situations which
require additional time, skill, or experience in
connection with the particular procedure.
The dentist might charge a fee in excess of the UCR amount. In
such case, the Plan payment is based on the UCR amount, and any
balance is owed by the patient.
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SERVICES & PLAN BENEFITS
Covered Dental Expenses
Covered Dental Expenses are the expenses incurred by or on
behalf of any employee or dependent for charges made by a
dentist for necessary services covered by the Plan while the patient
is eligible for Plan benefits.
Covered Dental Services
Your Dental Assistance Plan covers almost all dental services
which are essential for care of the teeth. Dental services covered
by the Plan are classified as:
Class I Services: Diagnostic and Preventative Services (100%
of UCR)

Diagnostic:
 Oral Examinations (Two per calendar year)
 X-Rays
 Emergency Treatment

Preventive:
 Cleanings (two per calendar year)
 Fluoride Treatments
 Space Maintainers
Class II Services: Basic Services (85% of UCR, subject to a
deductible)
 Anesthesia

Sealants (maximum of four quadrants per year)

Restorative, Minor
 Amalgam Fillings
 Composite Fillings

Endodontics
 Pulp Capping
 Root Canal Treatment
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
Periodontics
 Gingivectomy
 Periodontal Scaling

Prosthodontics, Maintenance
 Repairs to Dentures
 Relining Dentures

Oral Surgery
 Extractions
Class III Services: Major Restorative Services (60% of UCR,
subject to a deductible)

Restorative, Major
 Inlays and onlays
 Crowns (caps)
 Crown Build-Ups

Prosthodontics, Installation
 Dentures, Full and Partial
 Bridge Pontics and Abutments
NOTE: With few additions, procedure numbers and descriptions of covered
services are as published in American Dental Association, CDT-2, Second
Edition, 1995-2000. Any differences in wordings are for clarity and space
considerations. Questions should be directed to the Plan Manager: Health
Economics Group, Inc.
Benefits for Covered Dental Expenses
The term Covered Dental Expenses means the expenses incurred
by or on behalf of an Employee or Dependent for charges made by
a Dentist for Class I, Class II or Class III services covered by the
Plan while the patient is eligible for Plan benefits.
Payment will be made by the Plan at the following percentages of
the UCR for dental services:
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Class I
Class II
Class III
-
100%
85%
60%
However, for the first 2 years of a patient’s eligibility, the amount
payable for Covered Dental expenses incurred for the replacement
of teeth missing when the patient’s eligibility begins will be one
half of the amount otherwise payable for those expenses (42.5% of
Covered Class II and 30% of covered Class III services).
Expenses incurred by or on behalf of an Employee or Dependent
for a dental service begun while the individual is covered but
completed more than thirty (30) days after termination are not
covered by the Plan.
ANNUAL MAXIMUM BENEFIT
The maximum amount of benefits payable for each eligible
individual in any calendar year (January 1 – December 31) is
$1,000.00
PRE-TREATMENT ESTIMATES
If expenses for a dental service or a series of services are expected
to be $300.00 or more, the patient should ask the dentist to submit
a statement of planned treatment to the Plan Manager for review.
The Plan Manager will tell the dentist the amount of benefits
payable by the Plan for the work indicated.
Whether or not a pre-treatment estimate is requested, the amount
of expenses included as Covered Dental Expenses will be
determined by the Plan Manager taking into account alternate
procedures, services, or courses of treatment based upon
professionally endorsed standards of dental care.
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COORDINATION OF BENEFITS
If you or your family members are eligible to receive benefits
under another group plan, benefits from this plan will be
coordinated with the benefits from any of your other group plans
so that up to 100% of the “allowable expenses” incurred during a
calendar year will be paid by the plans.
An “allowable expense” is any necessary, usual, customary, and
reasonable expense covered in full or in part under any one of the
group plans involved.
A “plan” is considered to be any group insurance coverage or
other arrangement of coverage for individuals in a group which
provides medical or dental benefits or services on an insured or an
uninsured basis.
If a family is covered by another plan, claims should first be
submitted to the plan most closely associated with the patient.
Each spouse should first submit a claim to his or her own
employer’s plan. Claims for dependent children will be covered
first by the parent whose birthday (month and day, not year)
comes first in the calendar year.
In order to obtain all of the benefits available, you and your family
members should file claims under each plan. The Plan Manager
reserves the right to obtain and exchange benefit information from
any insurance company, organization, or individual to determine
the applicability of the Coordination of Benefit provisions. Should
an overpayment be made, the Plan Manager has the right to
recover the excess payment from the individual, insurance
company, or organization to whom the payment has been made.
CLAIMS ADMINISTRATION
With respect to claims administration, whenever an employee or
an eligible dependent has a dental appointment, he or she should
proceed as follows:
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
The employee will complete and sign the top portion of a claim
form indicating the name of the patient who is to be treated by
the dentist and the employee’s name and fill in other information
requested on the form. The employee will sign the section
authorizing release and use of claim information. If the
employee signs the section authorizing payment to the dentist,
any plan payment will be made payable to the dentist. If the
employee does not sign in this section, any plan payment will be
sent directly to the employee. If the dentist has indicated on the
claim form “Signature on File,” payment (if any) will be made
to the dentist. This is in keeping with the policy of the
American Dental Association.

The employee or the dependent will give the claim form to the
dentist. For dental work costing less than $300, the dentist is
expected to fill out the form upon completion of services and
send the form to the Plan Manager at the address printed on the
top of the form. Applicable benefits will be determined, and
payment will be made, by the Plan Manager.

If, for any reason, the employee is unable to obtain a claim form
in advance of treatment (for example, if an emergency service is
required or service is required outside of the greater Rochester
area), the employee should attach a copy of the dentist’s bill to a
claim form obtained as soon as might be convenient. After
completing the appropriate portions of the claim form, the
employee should send it to the Plan Manager.

The Plan Manager will pay the applicable benefit amount (for all
completed work) to the dentist or directly to the employee as
indicated on the claim form. Even if the employee does not
receive payment, he or she will receive an explanation of the
amount of benefits paid. Upon receipt, the explanation of
benefits should be examined for accuracy. Questions should be
directed to the Plan Manager.

When another dental appointment is scheduled, the employee
should obtain another claim form for the dentist to complete.
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Monroe Community College, through the Plan Manager, reserves
a right to deny payment relative to any claim form received by the
Plan Manager beyond one year of date of service. The first Plan
Year will be January 1, 2000 through December 31, 2000. Plan
Years thereafter will be January 1 through December 31.
SPECIFIC LIMITATIONS
Covered Dental Expenses will not include and no payment will be
made for expenses incurred:

For services performed solely for cosmetic reasons;

For replacement of a lost or stolen appliance;

For replacement of a bridge or denture within five years
following the date of its original installation unless (a) such
replacement is made necessary by the placement of an original
opposing full denture or the extraction of natural teeth or (b) the
bridge or denture, while in the oral cavity, has been damaged
beyond repair as a result of an injury received while the
Employee or Dependent is covered for Dental Expense Benefits;

For replacement at any time of a bridge or denture which meets
or can be made to meet commonly held dental standards of
functional acceptability;

For appliances or restorations, other than full dentures whose
primary purpose is to alter vertical dimension, stabilize
periodontally involved teeth, or restore occlusion;

For a temporary dental service (considered an integral part of the
final dental service rather than as a separate covered service); or

For which benefits are not payable under this policy according
to the section entitled GENERAL LIMITATIONS.
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GENERAL LIMITATIONS
No payment will be made under the Plan for expenses incurred by
an employee or a dependent:

For, or in connection with, an injury arising out of, or in the
course of, any employment for wage or profit;

For, or in connection with, a sickness for which the employee or
dependent is entitled to benefits under any Workers’
Compensation or similar law;

In a hospital owned or operated by the United States
Government, unless there is legal obligation to pay such charges
without regard to the existence of any insurance plan;

To the extent that payment under this policy is prohibited by any
law of the jurisdiction in which the employee or dependent
resides at the time the expenses are incurred;

For charges which the employee or dependent is not legally
required to pay or for charges which would not have been made
if no coverage had existed (for example, charges for completion
of a claim form);

For charges made which are in excess of the UCR/or UCR Class
IV services or for charges for unnecessary care or treatment.

To the extent that the employee or dependent is reimbursed,
entitled to reimbursement, or in any way indemnified for those
expenses by or through any public program other than the
program of Medical Assistance for Needy Persons established
by the State of the employee or dependent’s residence under the
provisions of Title XIX of the Social Security Act of 1965 as
amended. For the purposes of this paragraph, any individual
who, at any time, was entitled to enroll in all or any portion of
the Medicare program but who did not so enroll will be
considered to be entitled to reimbursement in any amount equal
to the amount to which he would have been entitled, if any, if he
or she were so enrolled.
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TERMINATION OF BENEFITS
Coverage for you and your dependents will cease upon
termination of your active employment, unless you qualify for
continued coverage as a result of an employment-related
agreement.
Coverage for dependents will cease when they no longer qualify
for eligibility.
If coverage terminates for you and/or one of your dependents,
benefits will be provided for expenses incurred within thirty (30)
days following such termination, provided that the expenses result
from dental work begun before termination. Any benefits payable
following termination of coverage are subject to applicable
maximum benefit levels for the Plan Year in which termination
occurs.
COBRA
(Consolidated Omnibus Budget Reconciliation Act of 1985)
If you, and/or your covered dependent(s) are not covered under
another employer-sponsored group health plan, immediately
following termination of eligibility for this Plan, you have some
important rights concerning the continuation of your group dental
benefits, if the coverage should terminate because of certain
events.
Listed below are the events that could cause you, and/or covered
dependent(s) to lose group dental coverage and the length of time
coverage can be continued if one of these events occurs.
1.
2.
3.
EVENT
Employee terminates employment (except
for gross misconduct)
Employee terminates employment due to
a disability
Employee’s hours are reduced
LENGTH OF TIME
COVERAGE CAN
BE CONTINUED
18 months**
29 months*
18 months**
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LENGTH OF TIME
COVERAGE CAN
BE CONTINUED
36 months
36 months
EVENT
Employee dies
Employee divorces or legally separates
from spouse.
6.
Employee becomes entitled to Medicare.
36 months
7.
Dependent child no longer qualifies as 36 months
dependent child under the Plan.
* The employee must meet the Social Security definition of “disabled”
in order for this provision to apply.
** If the covered person becomes disabled during the first 60 days of this
18-month period, the coverage can be continued for an additional 11
months (i.e., for a total of 29 months). The covered person must meet
the Social Security definition of “disabled” in order for this provision
to apply.
4.
5.
You must notify the Human Resources Department if you become
divorced or separated, or if your child no longer qualifies as a
dependent under the terms of this Plan, within sixty (60) days in
order to continue coverage.
The Human Resources Department will contact you or your
dependent(s) to enable election of continued dental coverage.
You or your dependent(s) will have sixty (60) days from the date
coverage would otherwise terminate or from the date the Human
Resources Department notifies you or your dependent(s) of the
rights to continue the coverage, whichever is later, to decide if you
want to continue coverage.
Any person who elects to continue the group dental coverage must
pay the full cost of the coverage, plus an additional 2% of that
cost. This includes the share that you may now pay. The Human
Resources Department will inform you and your dependent(s) of
the cost of the coverage when the notification is sent to you.
If you or your dependent(s) choose to continue coverage after the
event occurs, there will be a forty-five (45) day period for the
initial payment of the premium from the date you or your
dependent(s) choose to continue coverage.
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If the benefits or cost of the benefits change, you will be notified
of any such change.
CLAIMS REVIEW PROCEDURE
If you make a claim for benefits under the Plan, and all or part of it
is denied, you will be notified in writing of the decision within
sixty (60) days. Such notice will include the specific reasons and
provisions of the Plan upon which the denial is based.
If you do not receive notification of acceptance or denial within 60
days from submission of the claim, you may request review as if
the claim had been entirely denied.
Upon denial, you should, either in person, or by your duly
authorized representative:
1.
Review the claim with the Monroe Community College
Human Resources Department; and
2.
If you still believe there is an error, you may appeal the
decision within sixty (60) days.
This appeal must be in writing, including any additional
information to support your claim for benefits, and should be sent
to:
Monroe Community College
Department
1000 East Henrietta Road
Rochester, NY 14623
Human
Resources
Within sixty (60) days of your appeal, the Monroe Community
College Human Resources Department will notify you in writing
of the final decision and the specific reason(s) for this decision.
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ADMINISTRATION
The Plan will be managed on a day-to-day basis by the Plan
Manager.
All dental plan records for you and your family will be kept at the
office of the Plan Manager. A copy of the Enrollment Form will
be kept in the Monroe Community College Personnel Office. All
records will be kept confidential, except as may be necessary to
determine the appropriate level of benefits which are payable.
Plan Administration of a legal or regulatory nature is the
responsibility of Monroe Community College, which is officially
designated as the Plan Administrator. The Plan Administrator has
the final discretionary authority to determine eligibility for
benefits and/or to construe the terms of the Plan.
Plan Manager:
Health Economics Group, Inc.
1050 University Avenue, Suite A
Rochester, NY 14607
(716) 241-9500
Plan Administrator:
Monroe Community College
1000 East Henrietta Road
Rochester, NY 14623
(716) 292-2000
Plan Number:
The Plan Number is 502.
Plan Year:
The Plan Year is January 1st through
December 31st.
Benefit Year:
The benefit year is January 1st through
December 31st.
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