How the Dental HMO
(DHMO) Plan Works

Dental HMO Plan (effective 1/1/01) - The Dental Health Maintenance Organization plan, also known as the DHMO plan, has a network of preferred providers who agree to offer their services to you at a reduced cost. See the Important Telephone Numbers and Web Sites section of this handbook for more information.

You must choose a preferred provider from the network as your family's primary dentist. (All family members must use the same primary dentist.) If you enroll in the DHMO Plan, your out-of-pocket expenses may be less than if you choose the Dental PPO Plan. Another benefit of the DHMO Plan is that you do not have to file claim forms. There is no annual maximum.

Selecting a Dentist

The DHMO Plan requires you select one primary dentist for you and your covered dependents from the Participating Family Dentist List. Once you have chosen a primary dentist, that dentist will provide all dental care for you and your family until you elect another dentist (See Obtaining Care paragraph on page DHMO-2). Your primary dentist will refer you to a DHMO specialist if specialty care is required.

If you wish to change to another DHMO dentist or if the dentist that you originally chose when you submitted your Dental Plan Enrollment Form is not taking new patients, you must call the DHMO provider customer service unit. (See the Important Telephone Numbers and Web Site section of this handbook for more provider information) Before you will be allowed to change dentists, your account balance, if any, with your primary and/or specialty dentist must be paid in full.

Obtaining Care

When you call the DHMO dentist's office for an appointment, you will be asked to provide your Social Security number and the date of birth of the individual for whom the appointment is being made (you or your dependent). If the dentist that you chose when you submitted your Dental Plan Enrollment Form is no longer accepting new patients, you will have to select another dentist from the list.

The plan will not pay benefits if:

you go to a dentist who is not a member of the DHMO network other than for eligible emergency services (see "Emergency Pain Relief" on page DHMO-4); or

you receive services from a participating dental specialist without a referral from your primary dentist.

In these instances, you will be responsible for payment of all charges you incur.

Your Share of Expenses

Deductible and Maximum Benefit

Under the DHMO Plan, there is no deductible for you to meet before the plan begins to pay benefits. Also, there is no
pre-set maximum benefit that the plan will pay.

Co-payment

The DHMO Plan will pay 100% of all eligible diagnostic and preventive services for dental services. There are standard co-pays for dental services other than exams, x-rays, teeth cleanings and services which detect and prevent dental disease. The amount of the co-payment depends on the type of expense you incur. Your co-payments are made directly to your primary dentist. The Schedule of DHMO Benefits and Co-payments starting on page DHMO-4 lists the amount you must pay, if any, for covered dental procedures.

Other Charges

If you make an appointment with a DHMO dentist and find that you cannot keep it, you must call and cancel your appointment at least 24 hours in advance. If you fail to cancel your appointment, you may be charged a "missed appointment" fee by your dentist.

No Claim Forms to Complete

Under the DHMO Plan, there generally are no claim forms to complete. Your primary dentist will charge you only for your co-payment. However, if you go to a dentist in an emergency, other than your primary dentist, you must file a claim for reimbursement (See the Important Telephone Numbers and Web Site section of this handbook for more provider information).

What the DHMO Plan Covers

Refer to the Schedule of DHMO Benefits and Co-payments starting on page DHMO-4.

Diagnostic and Preventive Services

The following diagnostic and preventive services are covered at 100%:

oral exams - two exams a year;

emergency oral exams;

x-rays;

prophylaxis - teeth cleaning twice a year;

annual fluoride treatment to age 19; and

preventive care training.

Orthodontia

A standard two-year case of braces is available for each covered person under the age of 19, at a member cost of $2,000 a case. Effective January 1, 2003, the member cost is $2,100 a case. If the covered individual reaches the limiting age before completing orthodontic treatment, the orthodontic work in progress will not be covered.

Emergency Pain Relief

The DHMO Plan will reimburse you for emergency treatment received from a dentist other than your primary dentist. The plan will cover dental expenses related to minor procedures for the palliative relief of pain. You will be reimbursed up to a maximum of $50 for each occurrence. You will not be reimbursed for any treatment other than the immediate relief of pain. Before seeking emergency treatment, you must first contact your primary dentist for approval, unless you are more than 50 miles away from your dentist's office.

Schedule of DHMO Benefits and Co-payments

The following schedule lists most of the dental procedures available under the DHMO Plan and the amount you must pay, if any. This schedule represents the cost for each procedure. Multiple occurrences of the same procedure require a co-payment for each occurrence.

What the DHMO Plan Doesn't Cover

Although the DHMO Plan covers most of your dental care needs, there are some services that are not covered, such as:

hospitalization for any dental procedure;

any cosmetic or elective procedure;

home visits;

hospital bedside visits;

hospital administered anesthesia;

experimental procedures;

implantation;

pharmacological regimens;

prescription or over-the-counter medications;

convenience and personal items;

the settling of fractures or dislocations;

treatment of malignancies, cysts, neoplasms or

congenital malformations;

replacement of denture or bridgework previously supplied under the plan, due to loss or theft;
n covered services that are contraindicated because of the general health of the patient;

services which, in the opinion of the attending dentist, are not necessary for the patient's dental health;

services related to the treatment of temporomandibular joint (TMJ), except when those services are included in the Schedule of DHMO Benefits and Co-payments and are performed by the member's primary DHMO dentist;

missed appointment fees;

pedodontist fees;

prosthodontist fees;

second opinion fees incurred without prior authorization;

orthodontic work in progress;

any items covered under the Medical Care Plan;

services covered by Workers' Compensation or employer's liability laws;

services provided to the member, without cost, by any municipality, county or other political subdivision, other than Medicaid services; and

services of dentists or other practitioners of healing arts not associated with the DHMO Plan except upon referral by a contract dentist and authorized by the plan or when required in a covered emergency.

Who to Contact if You Have Questions

If you have any questions about the DHMO Plan, please call the DHMO provider customer service number. See the Important Telephone Numbers and Web Sites section of this handbook for more provider information.

Coordination of Benefits (COB)

Some individuals have dental care coverage in addition to this plan. For example, you may be covered as a dependent under your spouse's dental plan.

The City's Dental Plan works with other group plans to reimburse up to 100% of the allowable expenses for you and your dependents. An allowable expense is any expense covered at least in part by this plan. The maximum payable by the plan is limited to the amount that would have been paid if there was no other plan involved.

How COB Works

Here's how benefits are coordinated when a claim is made:

the primary plan pays benefits first without regard to any other plan; and

the secondary plan adjusts its payments so that the total benefit paid will not be greater than your allowable expense.

A plan without a coordinating provision is always the primary plan.

If all plans have a coordinating provision, here's how benefit payments will be determined:

The plan covering the patient directly, rather than as a dependent, will be the primary plan.

If a child is covered under both parents' plans, the plan covering the parent whose birthday comes first in a calendar year is the primary plan. If both parents have the same birthday, the plan of the parent who has been covered longer is the primary plan. If the other plan does ot have this rule but has a rule based on the gender of the parent, then the rule of the other plan will determine the order of benefits.

If you are separated or divorced, the order will be as follows:

- if the court has established one parent as financially responsible for the child's health care, the plan of the parent with that responsibility is primary; then

- the plan of the parent with custody of the child; then

- the plan of the step-parent married to the parent with custody of the child; then

- the plan of the parent that does not have custody of the child.

The City's plan will pay the benefits explained in this section of the handbook when this plan is the primary plan. When this plan is the secondary or later plan, it will usually pay the difference between benefits paid from the primary plan and the benefits provided by this plan. However, the total benefits paid will not be more than what would have been paid if this plan were primary.

Benefits are coordinated between dental plans in the following situations:

you are enrolled in the Dental HMO Plan as your primary plan and your other plan is PPO or an indemnity plan, or

you are enrolled in the Dental PPO plan and your other plan is a PPO or an indemnity plan.

If a Claim is Denied (Appeal Procedure)

If your eligibility for benefits is denied or if all or part of your claim is denied, you have the right to challenge the decision by sending a written request for review to your dental plan claims administrator.

If payment of your DHMO claim has been denied in part or in full by your DHMO Plan, the Plan shall notify you of:

The specific reason for adverse determination

The Plan provision on which the determination is based

A description of any additional information necessary for the Claimant to perfect the claim and an explanation why such information is necessary

A description of the Plan's review procedures and applicable time limits, including a statement of the Claimant's right to bring a civil action under 502 (a) of ERISA, if applicable, following an adverse determination of review

The following conditions apply in the case of an adverse benefit determination by a DHMO Plan or a Plan providing disability benefits:

If an internal rule, guideline, protocol or other criterion was used in making the determination, the notification must state that the criterion was relied on in making the determination and that a copy will be provided free of charge upon request.

If based on medical necessity, experimental treatment or similar exclusion, either an explanation of such exclusion applying the terms of the Plan to the Claimant's medical circumstances or a statement that such explanation will be provided free of charge upon request.

If you are not satisfied with the determination, please contact the Blue Cross and Blue Shield of Illinois (BCBSIL) Claim Review Section, P.O. Box 23089, Belleville, IL 62223. If, after investigation, BCBSIL determines that the claim (or portion of a claim) was correctly denied, you may appeal the denial as detailed below.

Under federal law, you are entitled to a full and fair review of the denied claim. Appeals must be made in writing within 180 days from the date you receive notice that your claim has been denied. You may submit written comments, documents, records and other information related to the claim for benefits with your appeal. You should also include any clinical documentation from your physician that would substantiate coverage of the denied claim.

You will receive a written decision within 60 days of receipt of your appeal request

Upon request and free of charge, you will be provided reasonable access to and copies of all documents, records and other information relevant to your claim, including:

Information relied upon in making the benefit deter-

mination

Information submitted, considered or generated in the course of making the benefit determination, whether or not it was relied upon in making the benefit determination
n Descriptions of the administrative processes and safeguards used in making the benefit determination

Records of any independent reviews conducted by the Plan

Dental judgments, including determinations about whether a particular service is experimental, investigational or not medically necessary or appropriate

Expert advice and consultation obtained by the Plan in connection with your denied claim, whether or not the advice was relied upon in making the benefit deter-mination

For insured products, Rule 9.19 of the Rules and Regulations of the Illinois Department of Insurance requires that the DHMO advise you that if you wish to take this matter up with the Illinois Department of Insurance, it maintains a Consumer Division in Chicago at 100 W. Randolph Street, Suite 15-100, Chicago, Illinois 60601-1115, and in Springfield at 320 W. Washington Street, Springfield, Illinois 62767-0001. By this notice, you are so advised.

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