Your group dental insurance plan : Flexible Benefits Program, state of Georgia

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FLEXIBLE BENEFITS PROGRAM
STATE OF GEORGIA

Underwritten By Phoenix
~PHOENIX
Phoenix Home life Mutual Instr.lnCe Company One American Row. Hartford, CT 06 115

tPHOENIX
CERT IFIES that it has issued and de livered a Group Insurance Policy to th e Policyholder shown below insuring certain Employees of the Employer show n below.
EMPLOYER: STATE OF GEORGIA (STATE MERIT SYSTEM AND DEPARTMENTS)
POLICYHOLDER: EMPLOYEE BENEFIT PLAN COUNCIL STATE OF ISSUE: GEORGIA GROUP POLICY NO.: 54-0000E EFFECTIVE DATE : JULY " 1987, AS AMENDED JULY " 1998
Th is cert ificate is furn ished in acco rdance with and subjec t to the provisions of the group po licies referen ced above and is issued to the EMPLOYEE BENEFIT PLAN CO UNC IL on beha lf of the STATE OF GEORGIA. Th e certificate is the certificate of cove rag e to be delivered to Employees who select denta l insu rance for Dental Expense Be nefits under the Flexible Benefits Program. The contract rights of an Employee insured unde r this gro up po licy will be gove rned solely by the po licy issued to the EMPLOYEE BENEFIT PLAN CO UNCIL. This group certificate is not a co ntract. It is merely a statement of the insurance provided by the gro up policy . The group policy is th e only contract . If questio ns arise, th e term s of the gro up po licy govern . Principal provisions of the group po licy wh ich apply to you are show n on the fo llow ing pages of this group certificate.

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GROUP DENTAL CERTIFICATE

This booklet is your certificate of benefits only when you speci fically elect Denta l Expense Benefits and Orthodontic Expe nse Benefits. The certificate is applica ble if you are entitled to the benefits provided by the gro up po lic y as an Elig ible Employee, and if you retain coverage in accordance with the terms and conditions of the group policy. This ce rti ficate is void if you are not entitle d to , o r have ceased to be entitled to the coverage. T his Certificate ca nce ls and re places any prior Dental Expense Benefits and Orthodontic Expe nse Benefits Certific ate issued to you by Phoe nix Home Life. This certificate describes the policy in effect as of July 1, 1998. NOTICE : UND ER PLAN B T HE P P O OP TION COVERED EX PENSE S ARE DETERM INED BY TH E SCH EDUL E CHARGE WHETHER OR NOT SE R V I CE S A RE RE NDE R E D BY PR EF ERR ED PROV ID ERS. FOR EXCEPTION SEE DENTA L EM ERGENCY . Except when otherwise indicated by the context of this certificate, any masculine terminology herein shall also include the feminine, and the definition of any terms in the singular may also include the plural. Th is group certificate is governed by the laws of the State of Issue shown above, which is the state of issue of the group policy.
Chief Executive Officer
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TABLE OF CONTENTS
Part 1: Insurance Schedule Employee and Depen dent Denta l Insurance
Part 2: Definitions Gene ral and Dental
Part 3: Eli g ibil ity Employee and Dependent COverage Premium Payments
Part 4: Determination 01 Benef its Part 5: Covered Dental Expenses
Employee and Dependent Dental Insurance Part 6: Exclusions Part 7: Coordination of Benefits Part 8: Tennination Prov isions
Employee and Dependent Dental lnsurance Part 9: Temporary Continuance of Coverage
Employee and Dependent Dental lnsurance Part 10: Retiree and Surviving Spouse/Dependent
Continuation of Coverage Part 11: General Provisions Part 12: How to File a Claim
Completing a Claim Form Appe als Part 13: Frequently Asked Questions
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PART 1: INSURANCE SCHEDULE
Dental Expense Benefits Employee and Dependents
Under the dental options. you may choose single or famil y coverage in:
The regular dental insurance plan (Traditional Option); or
A dental Preferr ed Provider Org ani zation (PPO) , jf you live in the metropol itan Atlanta, Augusta and Savannah area s, or if a PPO is available in your area.
Traditional (Indemnity) Option
Under the Traditional Option, benefits are determined by the lesser of the Usual or Customary Charge. You r Dentist is entitled to collect from you the difference between the amount of benefits payable by Phoenix Home Lite and the provider's Usual or Customary Charge for that service.
Preferred Provider Option (PPO)
Unde r the PPO Option, benefits are determ ined by th e Schedule Cha rge. If a Cove red Person utili zes th e services of a Preferred
Provider, that Provide r is entitled to collect from you the difference between the amount of benefits payabl e by Phoeni x Home Lite and the Sc hedule Charge . If a Covered Person utili zes the services of a Non-Preferred Provide r, th at Prov ider is entitled to collect fro m you the difference between the amount of benefits payab le by Phoenix Home Life and the provider's Usual Charge.
Your enrollment in the PPO Option is not with a particular Dentist, but is with the PPO program. PPO dentists can discontinue their arrangeme nt with the PPO program at anytime.
If you require the services of a spec ialist , ask your Dentist to refer you to a PPO specia list. If a PP O specia list is no t avai lable and you receive treatment from a non-PPO specialist, Phoeni x Home Life will pay the Provid er at a rate equal to what the PPO Denti st would have bee n paid. Th e non -PPO specialist ca n charge you th e differen ce between t he amou nt paid by Phoeni x Home Life and their normal billing amount for that service.
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Deduct ible

None

% insurance option pays

100%

Individual: $50

None

Family: Maximum $150

80%

50%

50%

% PPO option 100% pays

90%

50%

50%

Maximum Benefit (both options)

Preventive, Basic and Major in combination: $1,000 per Calendar Year per person

$ 1,500 lifeti me

Waiting Period None for benefits new Employees enrolling in either option or newlyenrolled Dependents

Waiting Period for ben efits current employees not already enrolled (Late Entrant Limitations)

None

On the first day of the month following six (6) months of continuous coverage

On the On the first day of the

first day month foUowing 24

of the

months of continuous

calendar coverage

month fol-

lowing 12

months of

cont inuou

covera ge

Only one ded uc ti ble app lies if bot h Bas ic and Major type expenses are incurred.

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PRE-DETERMINATION OF BENEFITS
W he neve r th e estima ted cost o f a rec om mended DE NT AL TREATMENT PLAN exceeds $500 . the DE NT AL TREATME NT PLAN must be submmed to Phoenix Home Life for its review befo re t rea tment beg in s. Bef ore Orth odontic Tr eatment begin s a n ORTHODONTIC TREATM ENT PLAN must be sub mitted to Phoenix Home Lite for its review. Phoeni x Home Life will send notification of the benefits payable based upon the DENTA L OR ORTHODO NT IC TR EATM ENT PLAN . In determinin g the amount of benefit s payable, co nsideration will be given to Alternat e Denta l Treatment that will, as determined by Phoe nix Home Life, acco mplish a professionall y satisfactory result. If you and the Dentist ag re e to a mo re cos tly method of t rea tment than that dete rmined by Phoe nix Home Life . the excess amount will not be paid by Phoenix Home Life. If a DENTAL TREAT MENT PLAN or ORTHODONTIC TREATMENT PLAN is not submitted to Phoen ix Home Lite, Phoenix Home Lite will no t p a y b en e f it s unti l a DE NT AL T R EAT ME N T PL AN o r OR T HO DONTIC TRE ATMENT PLAN is re ceived and approv ed by Phoenix Home Ufe.
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PART 2: DEFINITIONS
Accidental Bodily Injury means a bod ily injury resu lting direct ly from an acc iden t, not to include chewing injuries, and independently of all
other causes.
Actively At Work means that yo u must: 1. Be able to do the norma l tasks of your job on a full -time basis for
a full work day on the day yo ur insu rance is to beg in; and 2. Be ab le to do suc h tas ks at one of yo ur employer's normal
places of bus iness or at a location to which you must trave l to do your job; and 3. Not be absent from work beca use of sickness, disab ility or temporary lay-off . Benefit Year is t he Cale nda r Yea r du ring which de ductibles and maximum s are calcu lated while cove red unde r the plan . Ca lendar Year mea ns the per iod begin ning on Ja nuary t st and ending on December 31st of the same year. ChildfChildren means: Your unmarried : a) na tura l and adopted children, regardless of whet her they
reside in the household with you; and b) step chil d ren w ho res ide in the hou seh old with yo u in a
normal parent-ch ild relationsh ip; and c) other ch ild re n for w hom yo u h ave legal gua rd ians hip or
custody who res ide in the hou sehold with you ;n a normal parent-child relationship. Your unmarried children, as defined above, must also be: d) under nineteen (19) years of age; or e) age ninetee n (19 ) but less than twenty-six (26) years of age and are:
i) depe ndent on you for more than 50% of support; and ii) full-time st uden ts in a post-seco ndary instit ution o f
higher learn ing ; or
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iii) eligible to be full-t ime students in a post-secondary institution of higher learning but due to an injury or sickness are prevented from being a fu ll -time student.
f) a Handicapped Child as defined later in this section. Covered Person means you or your Dependent who is insured for DENTAL EXPENSE BENEF ITS.
Customary Charge means the fee for a service which Phoenix Home Life determines is the amount stanca roty charged by most denta l offices in the locali ty where the charge for such serv ice is incurred. Locality means an area whose size is large enoug h, as determined by Phoenix Home Life to give an accurate representation of standard charges for that type of service. Dental Emergency means a dental condition: 1. With a sudden, unexpected onset; and
2. Of such nature that failure to render immediate care could result in deterioration to the extent that either: a) the Covered Perso n's life or we ll-be ing is placed i n jeopardy; or b) serious impairments occur in the Covered Person's bodily functions.
Dental Hygienist is someone who is currently licensed to pract ice dental hygiene and is acting under the supervision and direction of a Dentist. Dental Treatment Plan means the Dentist's report of recommended treatment on a form satisfactory to Phoenix Home Ufe which: 1. Itemizes the denta l procedures and charges requi red for the
necessary care of the mouth; 2. Lists the Usual Charges for each procedure; and 3. Is accompanied by supporting x-rays and any other appropriate
diagnostic materials as required by Phoenix Home Life. Dentist is someone who is currently licensed to practice dentistry and is acting within the scope of his or her license.
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Department means any employing entity that is defined by state law as having employees eligible to participate in the Flexible Benefit Plan.
Dependent means: 1. Your spouse, if you are not legally separated or divorced; or
2. Your Child.
Eligible Employee means someone who:
1. Completes the waiting period (described in the "Date of Eligibility" section); and
2. Is a full-time Employee of the State of Georgia, or a State agency. "Full-time" means someone who works at least 30 hours a week, on a continuous basis, and whose employment is expected to last at least nine (9) months. The following are certain categories of employees specifically excluded: student, seasonal, part-time, short-term and sheltered-workshop:
3. Is a public school teacher who is employed in a professionally certificated capacity, works half-time or more and is not considered a "temporary" or "emergency" employee;
4. Is an Employee of a local school system who holds a noncertificated position and who is eligible to participate in the Teachers Retirement System or its local equivalent and working at least 18 hours a week (or 60% of the time necessary to carry out the duties of the position if that's more than 18 hours);
5. Is an Employee who is eligible to participate in the Public School Employee Retirement System as defined by Paragraph 20 of Section 47-4-2 of the Official Code of Georgia, Annotated and wh o works at least 18 hours a week (or 60% of the time necessary to carry out the duties of the position).
Employer (Eligib le Employer) means the Employer shown on the first page of this certificate.
Full-time Student means a Child who:
1. Is enrolled since attaining age 19 in a post-secondary institution of higher learning for five (5) calendar months or more in each calendar year; or
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2. Is e ligible to be so enrolled but is pre vented from being so enrolled due to Sickness or Injury.
Functio ning Natur al Tooth means that part of the tooth that is formed by the human body that: 1. Maintains arch length space; 2. Is utilized in the masticatory function; and 3. Is adequately supported by the surrounding structures. Handicapped Child means a Child who may be insured beyond the applicable age limit shown in the definition of Child, as long as: 1. Such a Child is:
a) Unmarried; b) Incapable of self-sustaining employment by reason of:
i) Mental retardation; or ii) Physical handicap; c) Dependent upon you for support and maintenance; and d) Insured: i) Under the policy upon attaining age 19; or ii) Under the policy prior to or upon atta ining age 26 , if
such Child is a Full-time Student; or iii) As a han dic ap pe d ch i ld u n d e r a Group Den tal
Insurance Plan of your Employe r immediately prior to the date on which your Employer became an Eligible Employer; and 2. At the following times, you submit on the Child's behalf Proof of such incapacity and dependency: a) Initially, within 90 days of whichever of the following dates is applicable: i) The date such Child attains age 19 if such Child is a Handicapped Child on his or her 19th birthday;
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ii) The date between the ages of 19 and 26 on which such Child incurs an injury or contracts a sickness that results in such Child's becoming a Handicapped Child, if such Child is insured as a Fun-time Student on such date;
iii) The date such Child atta ins age 26 if such Child is a Handicapped Child on his or her 26th birthday and was insured as a Full-time Student on the day immediately prior to attaining age 26; or
iv) The date on which your Employer became an Eligible Employer, if such Child meets the conditions of Item 1 above and is insured as a handicapped child under a Gro up De nta l In suran ce Plan o f your Emp lo yer immediately prior to such date;
b) During the 2 year period thereafter, at such other times as Phoenix Home Life may reasonably require; and
c) After 2 years, not more than once a year. Inc urred Date mean s a CO VERED DENTA L EX PENSE will be considered incurred as follows: 1. For full or partial dentures - on the date the final impression is
made. 2. For fixed bridges, crowns, inlays, onfays - on the date of the final
preparation of the teeth. 3. For root canal therapy - on the date the pulp chamber is opened. 4. For Orthodontic Expenses:
a) For cephalometric x-rays or study models - on the date the service was rendered; and
b) For all other expenses - on the date the appliance or bands are inser ted. (See PART 4: Determin ati on of Ben efi ts regarding payment of Orthodontic expenses.)
5. All other services - on the date the service is provided.
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late Entrant means someone who:
1. Complies with the " Condition s of In surab ility" for Denta l
Expense Benefits more than 31 days after he or she becomes
eligible; or
2. Requests reinstatement of insu rance which was terminated while he or she remained eligible for insurance under the policy.
Non- Preferred Provider means a Dentist or other provider who has not entered into a ser vice agree ment with Phoenix Hom e life to provide services at the pre-determined Schedule Charge.
Open Enrollment Period is an annual, thirty-one (31) day peri od during which Employees have an opportunity to enroll or change coverage (subject to Late Entrant penalties). The duration for Open Enrollment shall not exceed thirty-one (31) days and will begin no earlier than April 15 or later than May 1 of each year.
Option means the plan of Dental Expense Benefits that you elect on yo ur O ptio n Sta te ment and for which you ha ve agree d to th e co nditions of the Flexib le Benefit Plan. Alt hough the amount of coverage that is provided varies with each Option, both Options are subject to all the terms and conditions of the Dental Expense Benefits under the policy. The same Option that you elect for yourself will also apply to your Dependents. if any.
Opti on Stateme nt refers to the enrollment fo rm through which eligible emplo yees elect coverag e through the Flexibl e Benefi ts Program. The Option Statement is generated by the Georgia Merit System and contains basic employee data, eligibility information. and premium rates. The Option Statement serves as the binding salary reduction agreement through the IRC 125. cafeteria plan.
Orthodont ic Treatment means the corrective movement of teeth th ro ug h b one by me an s o f an ac tive app lia nce to correct a malocclusion of the mouth.
Orthodonti c Treat ment Pl an mean s th e Denti st 's rep ort of recom men ded or pl ann ed O rt hodontic Tre atm ent on a fo rm satisfactory to Phoenix Home Life which:
1. Itemizes the orthodontic procedures and charges required for correction of a malocclusion;

2. Lists the Usual Charges for each procedure; and 3. Is accompanied by supporting x-rays and any other appropriate
diagnostic materials as required by Phoenix Home Life. Phoen i x Hom e life means Phoen ix Home Life Mutua l Insurance Company, Hartford, Connecticut. Plan Year is the State of Geor gia Fiscal Period of July 1 through June 30. Preferred Provi der means a Dentist or other provider who has entered into a service agreement with Phoenix Home Life to provide services at the predetermined Schedule Charge. PPO means Preferred Provider Organization. Proof means any information that is: 1. Required by Phoenix Home Life under the terms of the policy;
and 2. Satisfactory to Phoenix Home Life. Usual Ch arge means the fee regularly charged and received for a given service by the Dentist's office. Schedule Cha rge means the pre-determ ined fee (that has been agreed to by Phoeni x Home Life and the Preferred Prov iders) charged and received for a given service by the Dentist's office in the area where the scheduled charge for such service is made. You (you, Your, you r) means the Employee.
PART 3: EMPLOYEE AND DEPENDENT COVERAGE ELIGIBILITY
Date of Eligibility (Waiting Period)
If you enroll for Dental Insurance under either the Traditional Option or the PPO Opt ion when you are first eligible (the hi re date as determined by your Employer or the Initial Open Enrollment Period for that Option):
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1. You and your eligible Dependents will be eligible for insurance for Preventive (Type I) and Basic (Type II) expenses on the first da y of the ca le nd ar mo nth foll ow ing one ( 1) full mo nth of employment. and
2. You and your eligible Depend ents will be eligibl e for insurance for Majo r (Type II I) expenses on the fir st da y of the mont h following six (6) months of coverage, and
3. Your eligible dependen t Children (under age 19) will be eligible for insurance for Orthodontic (Type IV) expenses on the first day of the month following six (6) months of coverage, and
4. A new depe ndent is automatica lly ins ured on the date of a cqui sitio n of new dep endent if yo u al re ady have famil y coverage.
If you do not ema il for Dental Insurance whe n you are first elig ible, yo u will be co nside red a Late Entrant with respect to Employee Insurance and you will be subject to the Limitation on Late Entran ts Section. If you elect to enroll in an Opt ion and subsequently elect to enroll in another Option, yo u will not be required to satisfy a new wa iti ng period with respe ct to Major (Type II I) and Orthodontic (Type IV) expenses.
Conditions of Insurability
You may enro ll for single coverage or you ma y e nro ll fo r famil y coverage. If you enroll for single coverage, you are the only person covered unde r the policy. If you enroll for family coverage , you and your eligibl e dependents are covered under the policy. The same Plan that you elect for yourself will also apply to your dependents. To become insured under the policy you must:
1. Complete and sign the Option Statement that is suppli ed to you by your Department; and
2. Make any required contribution toward the cost of the insurance as agreed to the conditions of the Flexible Benefit Plan.
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If you submit an Option Statement more than 31 days after the date you become an Elig ibl e Employee. you are a Late Entrant with respect to Employee Insurance and you wi ll be SUbject to the "Limitation on Late Entrants" section.
Premium Payments and Leave Without Pay
Prem ium s for coverage must be paid in advan ce of coverage . Normally, premiums are paid through salary reduction in the month prior to cove rage . Whe n an Employee is not in pay status. the Employee must submit the premium payment to the Employer prior to the first of the coverage month. If you are absent from work without pay for any reason, discuss co ntin ui ng your insurance with your personn el off ic er_ If you are ab sen t fro m wo rk and are on an approve d leave witho ut pay. your ins urance may be co ntinued through the twe lft h (12) calendar m onth after you cease wo rk. Failu re to continue your premium payments may result in Late Entrant Limitations. Should the Employee be placed in leave with out pay status after enrollment but before or on the scheduled effective date of coverage. premium payment while on leave without pay should not be made. If you are absent from work withou t pay for any reason, discuss continuing your insurance with your personnel officer.
Coverage Effective Date
If you meet the Conditions of Insurability, your coverage under the policy shall become effective on the later of: 1. The date of eligibility, provided you are Actively At Work. If you
are not Actively At Work on that day. the coverage will begin: a) The day that you return to work; or b) On the date of eligibility if it is your scheduled day off and
that you were Actively At Work on the preceding scheduled work day.
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2. July tst. provided you are Actively At Work , follow ing the initial Ope n Enrollment Period for either the Traditi onal Opt ion or the PPO Option, if you completed, signed and submitted the Option Statement during such Open Enrollment Period; or
3. July 1st, provided you are Actively At Work, following any Open Enroll ment Period subseq uent to the initia l Open Enrol lment Per iod for either Opt ion, if yo u complete, sign and submit an Option Statement during such Open Enrollment Period.
If you enroll for family coverage on your eligibility date, insurance for your eligible Depe ndents shall be effective on the same date as the effective date of your insurance, unless:
1. The Dependent is co nfined in an insti tuti on prov idi ng care or treatment for physical or mental infirmities on that date;
2. If the Dependent is so confined on that date, insurance for your De pe nde nt sha ll be co me e ff ective on the da te fo l low i ng dismissal from the hospital.
Limitation on Late Entrants
If you are a Late Entrant for these DENTA L EXPENSE BENEFITS, for the fi rst 24 months of cov erage your benefits will be limited as follows:
1. Benefits for the first twe lve months will be limited to Preventive (Type I) COVERED DENTAL EXPE NSES.
2. Ben e fits fo r the seco nd twe lv e mon th s will be l im ited to Preventive (Type I) and Bas ic (Type II) COVERED DENTAL EX PENSES .
If you te rmi nate you r cove rage under the policy and then later reenroll under the plan, the above limitations will apply from the date on which your insurance is reinstated. Any tim e period for which your insurance was effective prior to your reinstatement cannot be used to satisfy the time limitations stated above.
No Major (Type II I) Den tal Expense Be nef its ar e payab le for a Cove red Person until Dental Expense Benefits have" bee n in force wit h respect to the limitat io n of late entra nts for 24 co nsecut ive months.
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No Or thodontic (T ype IV) Expense Benefits are payable for a Covered Person until coverage has been in force with respect to such Covered Person for 24 consec utive months. Upon comp letio n of such 24 consecutive month period, such Covered Person will then be eligible for the lifetime maximum benefit as described in the Maximum Benefit section.
Opportunities to Enroll or Change Coverage
1. If you choose not to elect coverage when firs t eligible (refer to the sect ion entitled "Date of Eligib ility " under PART 3) or you disco ntinue coverage during an Open Enrollment Period, you can elect or re-e lect coverage dur ing subseque nt Ope n Enro llmen t Periods. Please refe r to the Limitati on on Late Entrants section on the prior page.
2. During an Open Enro llment Period, you can change coverage type and/or option. Coverage may be limited for persons added during Open Enrollment periods.
3. If you choose single coverage upon your eligibility date, you may change to family coverage upon acquisition of a newly eligib le Dependent (e.g., marriage, birth, adoption). You must, however, file a written request for a change in your coverage through your department within thirty-one (31) days of such change in family status. The effective date of coverage for the Dependent(s) shall be the first of the month following the appropriate premium payment. Your newly eligible Dependents will not be subject to the Late Entrant Limitations. Newly eligible Dependents will be requ ired to meet a six (6) month waiting per iod for Major and Orthodontic Expenses.
4. If you lose (e.q., death, divorce, child exceeding eligible age) all eligible Dependents , you may change from family to single coverage. Yo u must, however, file a wr itten request for a change in your coverage through your department within ninety (90) days of such change in family status. If no change request is filed within the ninety days, a change will not be permitted until the next Open Enrollment Period.
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5. If you or your Dependent(s) lose dental coverage because the employment status of your spouse changes (e.g., termination), you may enroll in single or famil y cove rage or change fro m single to family coverage, if you file the request within thirty-one (31) days of the event. Persons added to coverage will not be subject to the Late Entrant Limitations, but will be subject to a six (6) month waiting period.
6. Jf yo ur spo use ga ins co ve rage thro ug h th eir cha nge of employment, you may change from family to single coverage or disco ntinue family or sing le coverage if you file the request within ninety (90) days following the event.
Increases in Insurance
If for any reason there is an increase in the amount of insurance or bene fits for which you are eligible , you will be insured for suc h increased amount or benefits on the date of the increase provided you are Actively At Work on that date. Otherwise, you will be insured for such increased amount or benefi ts on the date you are again Actively At Work.
If you are not Active ly At Work on such date solely because such date was not a regularly scheduled working day, you will be deemed Actively At Work on that date.
If there is an increase in the amoun t of insurance or benefits for whic h you are eligible wit h respec t to yo ur Depe ndent, yo ur Dependent will be insured for such increased amount or benefits on the date of the increase, subject to the Actively At Work prov ision mentioned above. Such Dependent, however, must not be confined in an inst itution providi ng care or treatment of physical or mental infirm it ies on that date. If t he Depe nde nt is so con fined, suc h Dependent will be insured for such increased amount or benefits on the date following dismissal from the hospital.
Decreases in Insurance
If there is a decrease in the amount of insurance or benefits for which you are eligible , you will be insured for such decreased amount or benefits on the date of the decrease.
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PART 4: DETERMINATION OF BENEFITS
Benefits Payable
Type I, II and III:
If during a Calenda r Yea r a Cove red Perso n incur s COVERED DENTA L EXPENSES in excess of the Deductible (if applicable), Phoenix Home Ufe will pay to you a benefit equal to the applicable percentage shown in the Insurance Schedule of Preventive (Type I), Basic (T y pe II ) and/o r Ma jor (Type III ) COVERE D DEN TAL EXPE NSES incu rred in excess of the app licable Ded uctible, subject to the Maximum Benefit and applicable Customary Charges .
Orthodontic (Dependent Child) Expenses Type IV:
Upo n receipt of proof of claim that any Covered Person has incurr ed Covered Orthodontic Expenses:
1. The benefit payable will be subject to:
a) 50% of the Covered Orthodontic Expenses; and
b) The Lifetime Maxim um Benefit; and
2. The benefit will be payable according to the following method:
a) The initial benefit payable will:
i) be d e te rm i n ed by t he amount cha rged for the diagnosis and/or placement of the bands or appliance; and
ii) not exceed 30% of the total benefit; and
b) Any remain ing benefit ava ilable for Cove red Ort hodo ntic Expenses for monthly adjustme nts will be payable on a 3 ' month payment schedule as long as treatmen t cont inues and insurance is in force; and
c) In no event will the total benefit be payable in one sum at the start of treatment.
Any benefits payabl e wil l be subject to the re quiremen t of the Orthodontic Treatment Plan that has been reviewed and approved by Phoenix Home Life. If it is determined by Phoenix Home Life that an Alt ern ate Dental Trea tme nt Pla n will produce a professio na ll y satisfactory result, such benefits will be payable under the terms of the policy.

Genera l Information
W ith respect to the PPO Option, if you ca nnot reasonably travel to a Prefe rred Pro vide r and th ere is a Dental Emergency and you are unable to uti lize the services of a Preferred Provide r due to the De ntal Eme rgency , the lesser of the Usu al Charge or the Cu stomary Charge for a given dental se rvice in the area where the charge for the service is made will app ly to services or supplies when ren der ed by a Non-Preferred Provider during the course of the Dental Emergency. If yo u elect an Opt ion and subsequently elect another Option , the Cas h Ded uct ible, Max imu m Benefit and any othe r limits on amounts or time limitation on benefits payable under your current Option will be red uced by any correspond ing amounts or limitati on s previous ly pai d or satisf ied , whether in who le or in part under the ter ms of yo ur prior Option .
Deductible
A deductible is t he amou nt t he in sure d is requ ired to pay eac h Calendar Year before any Denta l Expen se Benefits are payable.
The Per Person Deduct ible per Cal enda r Year fo r Basic (Type II) and/or Major (Type III) Co ve red Expenses is shown in the In su rance Sc hed ule . The amounts to be applied to meet the Deductible mu st be charges for COV ERED DENTAL EXPE NSES.
Deductible amounts applie d for you r fa mily will not e xceed in any Cal enda r Year , t he Max im um Fa m ily Ded uctible shown in th e In surance Sc hed ule even if the Per Person Deductible has not been me t.
Maximum Ben efit
T he Per Person Maximum B e ne fit in each Ca lenda r Yea r f or Preve ntive (Ty pe I), Basic (Type II), and Major (Type III ) expenses combined is shown in PART 1: Insurance Schedule (refer to page 5).
The Calendar Year Maximum Benefit app lies to all periods of time the Covered Person is insured during a Calendar Year regardless of any interruptions in cove rage for this insurance.
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The Llfetlme Maximum Benefit for any Covered Person who incurs
Covered Orthodontic Expenses is shown in the Insurance Schedule.
The Lif etim e Max imum Benefit app lies to all periods of time the Covered Person is insured for DENTAL EXPENSE BENEFITS under the po licy, regardless of any interruptions in coverage for th e insurance.
Alternate Dental Treatm ent
If Phoenix Home Llte determines that alternate procedures, services or courses of treatment can be performed to correct a dental condition, payment will be considered for the least costly procedure which Phoenix Home Ufe determines will produce a professionally satisfactory result.
Favorable Resul t of Treatmen t
Benefits will be considered only for treatment that Phoenix Home Life determines has a reasonably favorable prognosis.
Benefits For Temporary Work
Benefits for temporary dental service (including temporary prosthetics) wi ll be considered a part of the final dental service. Benefits paid for the temporary ser vice wil l be deducted from the benef its otherwise payable for the fina l service. By temporary prosthetics we mean any prosthetic inserted and utilized by a Covered Person for fewer than 12 months (e .q. temporary cap , temporary bridge , temporary partial; temporary work that is not permanent). Any prosthetic inserted and utili zed by a Covered Person for at least 12 months will be considered permanent in nature and item 5 of EXCLUSIONS (see page 29) will apply.
Benefi ts After Termination of Insurance
General Information
No benefits will be available for charges incurred after a Covered Person's insurance ends except for COVERED DENTAL EXPENSES incurred for treatment that is:
1. Started while a Covered Person is insured; and
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2. Fin ished withi n 90 days after the Cove red Person's insurance ends.
This exte nsion is limited to crown s, fixed bridges , inlays, onlays, veneers, full dentures, partial dentures and root canal therapy . A predeterm ination for any Denta l Treatment Plan does not constitute treatment started. Orthodontic Expense Benefits Orthodontic Expense Benefits will be paid after insurance terminates onl y unti l the end of the month in which cove rage termin ated. If a De pen dent Child , who is a Co ve red Pe rs o n, att a ins age 19, Orthodontic Expense Benefits will continue to be paid if: 1. The appliance or bands were inserted while the Dependent Child
was under age 19 ; 2 . Or thodonti c Treatment continue s in a ccordance wit h the
ORTHODONTIC TR EATMENT PLAN approved by Phoenix Home Ute; and 3. You continue to be insured for DENTAL EXPENSE BENEFITS.
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PART 5: COVERED DENTAL EXPENSES
For any of the de ntal serv ices listed below , when tho se services are per formed by a Den tis t or Dental Hygien ist and are essential, as det er min ed by Phoen ix Hom e Lue. fo r the nec essary dent al or orthodontic car e of a Covered Person , an d whic h have a fa vo rable prognosis. as det ermi ned by Phoenix Ho me Life. a COVERED DENTAL EXPE NSE and COVERED OR THO DONTI C EXPENSE are:
1. With respect to the Trad itional Option, the lesser of the Usua l Charge or the Customary Charge;
2. With respect to the PPO Option , the lesser of the Usu al Charge.
the Customary Cha rge or the Schedule Charge;
The following is a com plete list of thos e denta l servi ces wh ich will be cons idered as CO VER ED DENTAL EXPENSES; however , expenses that are incurred for the perfo rmance of any dental service not listed below will be conside red a CO VERED DENTAL EX PE NSE only if Ph oeni x Ho me Lif e agr ee s in writing to accept suc h e xpe nses as CO VER ED DENTA L EXPENSES. If Phoenix Home Lif e so agrees, t he b ene f it that Phoen ix Hom e Life p a ys w ill be co ns iste nt, as determined by Phoenix Home ure . with a pa yme nt for suc h similar COVE RE D DENT AL EXPENSE S that wo uld provide the least costly professionally adequate trea tment.
Type I: Prev entive Dental Services
Oral Examination
Initial - An initial examination is the Dentist's first contact with a new patient an d incl udes a co mplete ev aluation of the patient's oral condit ion.
Pe r io dic A pe rio di c exam ina tion in volve s a c heck o f the panent's oral cavity .
Traditional Option - Benefits for oral examinations are limit ed to 1 initial or pe riodic exam in a 6 consecutive month period.
PPO Option - Be ne fits for oral e xa mina tio n s are li mi ted to 1 e xam in a 6 month period . Initi al examinations are 1 time in a 12 con sec utiv e month pe ri od subj ect t o t h e 1 tim e in 6 month limitati on. (e.g. 1 initial e xamination and 1 peri odic exa mination in a 12 month pe riod wit h a s ix mon t h t ime spa n b etwee n exa rmnations.)
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X-rays Complete Series or Panorex X-rays - Complete series consist of at least 10 periaplcals and may also include either two to four bitewing x-rays. Pancrex x-rays are films that produce a single image of the facial structure. Benefits are limited to 1 time in any 36 consecutive month period. Individual Periapical X-rays - These films are intended to show all of a tooth, including it's surrounding structure. Occlusal X-rays - The se films allow a Dentist to see a larg er area of the maxilla (upper jaw) and mandible (lower jaw). Extraoral X-ra ys - X- ra ys tak en with the film outs ide of the mouth . Benefit is limited to 1 film in any 6 consecuti ve month period. Bite-Wing X-rays - These x-rays are most commonly used to detect decay of the teeth . Benefit is limited to 1 time in any 6 consecutive month period.
Dental Prop hyl axis and Fluorid e Treatments Prophylaxis means a professional teeth cleaning by a Dentist or Dental Hygienist. Benefit is limite d to 1 time in an y 6 consecutive month period. Fluoride is used as a means of preventing tooth decay. Benefit is limited to 1 time in any 6 conse cutive month period and to Covered Persons under the age of 16.
Space Maintainers for missing deciduous (baby or primary) teeth Benefit is limited to Covered Persons under the age of 14. Benefits include all adjustments within 6 consecutive months of installation. Biopsy - A biopsy is the surgical removal of tissue for microscopic examination. Palliative Treatm ent - Minor procedures performed to relieve, not cure, emergency dental pain. Paid as a separate benefit only lf no other service, except x-rays, was rendered during the visit.
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Sedative Fillings - Used to relieve emergency denta l pain. Paid as a separate benefi t on ly if no other se rvi ce, except x- ray s. was rendered during the visit.
Type II - Basic Dental Services
Diagnostic Cast s - A plaster or stone model of teeth and adjoinin g ti ssu e . Ben ef it is lim ited to 1 time in an y 24 con secutive m ont h period. Restorative Dentistry - The repairing of teeth that may be necessary as a result of tooth decay or Accidental Bodily Injury.
Amalgam Restora tio ns (or "S ilv er Filli ng") - Used to restore posterior teeth. Multiple restorations on 1 surface will be treated as a single filling. Composite Restor ations - A plastic, resin, acrylic or silicate filling used on anterior (front ) teeth . Not cove red for posterior (back) teet h. Other Restorative Procedures Stainless Stee l Crowns - Hard metal shells con tou red to fit over a t oo th . Used when to oth ca nnot be rest or ed wit h fi lling material. Pin Re tenti on - Not cov e red in addit ion to cast restorati on s except under unusual circumstances as determined by Phoenix Home Life. Benefit is limited to 2 pins per tooth. Recementation - Provided for Inlays, Crowns and Bridges. Repairs to Full Dentures. Partial Dentures , Bridges - Benefit is lim ited to repairs or adjustme nts of that applia nce do ne mo re than 12 months after the initial insertion. Relini ng Dentures - Benefit is limited to relining done more than 12 mon ths afte r the initial insertion and the n not more than 1 time in any 24 consecutive month period.
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Endodontics - The branch of dentistry that deals with the diagnosis and treatment of d iseases of the tooth pulp and the associated periapical areas (area around the end of the root).

Pulpotomy - means a partia l removal of the damaged pulp of a tooth. Benefit is limited to deciduous teeth only.

Root Cana l Therapy - The treatment of disease or injuries of the pulp and associated with a port ion of the root of the tooth .

Other Endodontic Procedures

Apicoectomy/Retrograde Filling - Apicoectomy is the surg ica l removal of the apex of a tooth root. Retrograde Filling is the placement of a filling on the tooth root upon complet ion of the apicoectomy.

Hemisection - is the remova l of approximately one-half of a multirooted tooth.

Periodontics - The branch of de ntistry dealing w ith the prevention, diagnosis, and treatment of diseases of the bone and gum tissue which surrounds and supports the teeth.

Scaling and Root Planing - is non-surgical treatme nt performed for patients with periodo ntal disease. Benefit is limited to 2 times per quadrant of the mouth in any 12 consecutive mo nth per iod. See item 17 f) of EXCLUSIONS.

Provisiona l Splinting - Temporary or pe rmanent stab ilization of teeth that may become mobile due to periodontal disease.

Periodontal Appliance - Benefit is lim ited to 1 appliance in any 36 co nsecutive month period. Benefits include all repairs and adjustments within 12 consecutive months of installation.

Oral Surgery

Simple Extraction - The removal of a tooth that is fu lly erupted and accessible for removal.

Surgical Extraction of Impacted Teeth :

!SOft Removal of tooth

tissue)

Removal of tooth partial bony)

Remo val of tooth full bony)

Root Recovery - A procedure required when the crown of a tooth has been totally resorbed from disease or parts of roots are retained over a period of time as a result of fracturing at the time of the initial extraction.

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Incision and Drainage - Prov ided to treat a local ized area of acute or chronic inflammation containing pus. Removal of a Cyst - A cyst is a pathologic space in bone or soft tissues, containing fluid or semi-fluid material. Ge ne ra l Anesth es ia - Benefit will be paid for as a separate procedu re only when required for extraction of impacted teeth . See item 18 of EXCLUSIONS.
Type III: Major Dental Services
Frenecto my - Surgical proced ure that may be performed to avoid a space between two ad jacent teeth, or as an a id in orthodontic treatment, to correct restricted tongue movement, or to facilita te the placing of dentures. Major Restorative Proced ures
Initial Metallic Inlays and Onlays - Covered only when the tooth cannot be restored by silver fillings. Rep lacement of Meta llic Inlays and Onlays - See item 5 of Exclusions Porcelain Restorat ions (veneers and crow ns) - Covered only if the tooth cannot be restored by a filling or by other means. Initial Crowns - A cro wn is a fixed resto ration which covers the corona l portion of the tooth. Covered only if the tooth cannot be restored by a filling or by other means. Crowns are not covered if placed for the purpose of periodontal splinting. Replacement Crowns - See item 5 of EXCLUSIONS.
Gold Post and Core - Used to restore teet h that have had root cana l treatment and are badly broken dow n. Covered only for teeth that have had root canal therapy. Periodontics Osseous Graft - Osseous (Bone) Grafts are used to replace alveo lar bone that has bee n lost due to periodonta l disease. Covered only if a medical claim for such procedure is submitted and subsequently denied in writing.
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Soft Tissue Graft - Used to replace damaged, lost or otherwise inadequate gingival tissue. Covered only if a medical claim for such procedure is submitted and subsequently denied in writing. Occlusal Adjustment - This procedure involves reshaping the occlusal (the chewing surface of a posterior tooth) surfaces of the teeth . Cove red only when performed in connection with Periodontal Surgery. Benefit is limited to 1 time per area of the mouth in a 12 consecutive month period. Pr osthodonti cs - The branch of denti str y co nc erne d wit h the replacement of missing natural teet h and other tissues by artificial appliances. Initial Full or Partial Dentures ~ See item 8 of EXCLUSIONS. Replace me nt of Fu ll or Partia l Den tures - See item 5 of EXC LUS IONS. Initial Fixed Bridges - See item 8 of EXCLUSIONS. Replacement of Fixed Bridges - See item 5 of EXCLUSIONS.
Type IV: Dependent Child Orthodontic Expenses
Cephalometric X-rays - x -rays tha t sho w the size, contour, architecture, den sity, an d positi on of the skull bones. Benefit is limited to 1 time in any 2 year period. Ort ho dontic Treatment - The dental specialty that deals with the diagnosis, prevention, and correction of irregularities of the teeth and surround ing structures. Benefit is limited to malocc lusion (means "improper bite") as determined by Phoenix Home Life. Study Model s - Benefit is limited to 1 Study Model per Covered Person. Orthodontic (Type IV) Expenses are limited to your Dependent Child who is under age 19.
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PART 6: EXCLUSIONS
COVERED DENTAL EXPENSES do not include and no benefits are provided for: 1. Procedures which are not included in the li st of COVER ED
DENTAL EXP ENSE S. 2. Procedures wh ic h Phoenix Home Life determines to be
unnecessary . 3. Procedures which Phoenix Home Life determines do not have
uniform professional endorsement. 4. Procedures relat ed to the change of ve rtica l dimension ,
restoration of occlusion, bite registration, or bite analysis. 5. Charges for replacement of bridges, pa rtial or full dentures,
inlays, oruays or crowns:
a) if th ey can , as determined by Phoeni x Home Life , be
satisfactorily repaired and restored to function; b) during the first 24 months th es e DENTAL EXP ENS E
BENEFITS are in effect for a Covered Person, if within 120 consecutive months (1 a years) of the date of insertion; or c) after the f irst 2 4 months these D ENT AL EXP ENSE BENEFITS are in effect for a Covered Person, if within 60 consecutive months (5 years) of the date of insertion. Except ions to e xclusions 5b and 5c will be mad e if the replacement is made necessary by: i) the extraction of a Functioning Natural Tooth; or ii) Accidental Bodily Injury. Such Injury must occur while the Covered Person is insured under the policy. Chew ing injuries are not considered Accidental Bodily Injuries.
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6. Implants, lost or stolen appliances, precision or semi-precision attac hments. over dentures or customized prostheses, denture duplication, or other customized attachments.
7. Procedures that Phoenix Home Life determines are cosmetic in nature (e.g. bleaching, whitening).
8. The initial placement of partial or full dentures, or bridges jf the prosthesis includes the replacement of teeth missing prior to the effective date of the Covered Person 's coverage includi ng congenita lly missing teet h. This exclusion will not apply if the prosthesis replaces a Functioning Natural Tooth that is extracted by a Dentis t while the Covered Per son is insu red unde r the policy.
9. Charges for any of the following: a) dental care arising out of or in the course of employment for payo r profit or which is covered by Workers' Compensation or a similar law; b) care, treatment , services or supplies which are furnished, paid for or reimbursable by any government or subdivision of qovemrnent. This restriction will not apply: i) to the extent that the Covered Person is required by law to pay such dlarges; ii) to charges incurred by a veteran for a non-service connected Sickness or Injury; and iii) to cha rges incurred by retired veterans or Depe nden ts of veterans co nfi ned in a mi litary hospital; c) dental care resulting from any injury sustained as a result of war, declared or undeclared. or any action of war or any resistance to armed invasion or aggression or international police action; d) failure to keep appointments;
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e) dental care resu lting from any injury wh ich is selfinflicted or not caused by an accident;
f) dental care resu lt ing from participation in t he commission of a felony;
g) dental care resulting from active participation in a riot;
The words "participation" and "riot" in the phrase "participation in a riot" will be defined as follows: Participation - includes promoting, inciting, conspir ing to promote or incite, aiding, abetting , and all forms of taking part in, but will not include act ions taken in de fense of public or private property, or actions taken in defense of the person of the insured, if such actions of defense are not taken against persons seeking to maintain or restore law and order including but not limited to police officers and firemen.
Riot - includes all forms of public violence, disorder, or disturbance of the public peace, by three or more persons assembled together, whether or not acting with a common intent and whether or not damage to person or property or unlawful act or acts is the intent or the consequence of such disorder; and 10. Treatment of temporomand ibular joint dysfunct ion (TMJ) and orthoqnathic surgery. 11 . Charges made by a Dentist or Dental Hygienist who:
a) normally lives in the Covered Person's home; or b) is a member of your immediate family.
Immediate family is limited to: i) you;
ii) your spouse; and iii) parents, brothers, sisters or children of either
you or your spouse, whether related by blood or marriage.
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12. COVERED DENTAL EXPENSES incurred while insurance is not in force.
13. Charges for care, treatment, services, or supplies to the extent that any benefit is provided by Medicare.
14. Charges which are not customarily made when there is no insurance, or charges for which there is no legal obligation to pay.
15. Denta l care which is not customari ly performed or which is experimental in nature, or for implantology.
16. Charges for sealants, oral hygiene, a plaque control program or dietary instruction.
17. Charges for any of the following: a) Surgery necessary to repair a Functioning Natural Tooth and tissue due to accidental injury; b) Gingivectomy; c) Alveolectomy; d) Gingival Curettage; e) Osseous surgery; and f) Other procedures covered by the Standard and High options of the State Health Benefit Plan whether or not benefits are paid under such expenses.
18. Any expense covered in whole or in part under any other plan of benefits or sponsored by the Employee's Employer whether or not benefits are paid under such plans as to such expenses.
PART 7: COORDINATION OF BENEFITS
Use of Co ordination of Benefits (COB)
In computing the benefits payable under This Plan, the benefits from other Plans will be taken into account. This may require a reduction in benefits under This Plan, so that the combined benefits will not be more than the Allowable Expenses of This Plan and any other Plan.
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Definitions
Plan mean s any pl an provid ed by any employer o r any other plan req uired by law that pr ovid es denta l expe nse benefits or services und er an y group i nsurance or an y oth er i nsured or unin sur ed arrangement of coverage for which any employer:
a) contributes all or part of the cost; or
b) makes payroll deductions. Benefits payable under another Plan include the be nefits that woul d have been payable if claim had been made for them.
This Plan means your Employer's Plan of DENTAL EXPENSE BENEFITS with Phoenix Home Life.
Allowable Expense mean s an y necessary , reasonable , and customary item of CO VER ED DEN TAL EXPENS E (as defined in PARTS 5 and 6) that is at least part ly covered under at least on e of the Plans covering the person for whom claim is made.
When a Pla n prov ides ben efits in the form of se rvices rather than cas h. the va lue of each service rendered wil l be co nsidered to be both:
1. An Allowable Expense; and
2. A benefit paid.
Computation of Benefits under COB
Specifically, in a Calen dar Year, Thi s Plan will always either pay its regular benefi ts in full, or it will pay a red uced amou nt wh ich, whe n added to the benefits payable and the cas h va lue of any se rvices provided by the other Plans , will equal 100 % of the Allowable Expenses incurred by the person for whom claim is being made.
Order of Benefit Determination
To ad ministe r this pro vi si on pro perly, and to dete rmi ne whethe r Phoenix Home Life will reduce the benefit that would have been paid if COB had not been included, it is necessary to determine the order in which the var ious Plans will pay benefits. This will be determin ed as follows:
1. A Plan with no COB provisi on will be consi de red to pay its benefits before a Plan that contains such a provision .
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2. A Plan that covers a person other than as a dependent will be cons idered to pay its benefits before a Plan that covers that person as a dependent. In other words, the plan cove ring the claimant as an insured will pay benefits before the plan covering the claimant as a dependent.
3. ''The birthday rule" - A Plan that covers a person as a dependent of an employee whose month and day of birth occur earlier in the calendar year will be considered to pay its benefits before a Plan that cove rs that person as a dependent of an employee whose month and day of birth occur later in the calendar year (e.g. The mother's birthday is April 2nd and the father's birthday is June 3rd. The mo ther's plan would be primary and the
fa ther's plan would pay as secondary on the dependen t
children's claims. It both the parents have the same birthday, the plan which has been in effect the fongest will be prima ry). If, however, the COB provisions of any other Plan do not contain a rule like the one described in the preceding sentence, then such rule will not apply and the applicable rule set forth in such other Plan shall determine the order of benefit payment.
4. If, however, the parents of a dependent child are sepa rated or divorced the following rules apply:
a) if there is a court dec ree that sets respons ibility for the child's health/dental care, a Plan that covers the child as a depe nde nt of the parent with such responsi bility will be considered to pay its benefits before any other Plan that covers the child as a dependent child; otherwise
b) if the parent with custody of the child has not remarried, a Plan that covers the child as a dependent of that parent will be considered to pay its benefits before a Plan that covers the child as a dependent of the parent without custody.
c) if the parent with custody of the child has remarried:
i) a Plan that cove rs the child as a dependen t of that parent will be considered to pay its benefits before a Plan that covers that child as a dependent of the stepparent; and
ii) a Plan that covers such child as a dependent of the step -parent wi ll be co nside red to pay it s benefits before a Plan that covers the child as a dependent of the parent without custody.
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d) If specific terms of the court decree state that the parents shall have joint custody without stating that one of the parents is responsible for the dental expenses of the cnno. the Plan(s) covering the child shall follow the rules outlined in 3 above.
5. Whe re 1, 2. 3 and 4 above do not establi sh the orde r of payment, the Plan under which the person has been covered for the longer period of time will be considered to pay its benefits before the other. However: a) a Pla n tha t co ve rs a person as a l aid-off or retire d emplo yee , or as a dependent of such a perso n, will be considered to pay its benefits after a Plan that covers such person as other than a laid-ott or retired employee, or as a dependent of such a person. b) if th e other Pl an doe s not contain a rule lik e th e on e described above in item 5-a, then such rule shall not apply.
Rights Under COB
Phoenix Home life has the right to release or obtain any information and make or recover any payment s Phoeni x Home Lite considers necessary in order to administer this provision.
PART 8: TERMINATION PROVISIONS
Termination of Employee and Dependents Insurance
The DENTA L EXPE NSE BENEFITS cove rage for you and your Dependents will automatically end on the earliest date shown below: 1. On the date you are no longer Actively At Work except that:
a) while you are sick or inj ured. and in an approved leave without pay period, your employment will be deemed to continue for up to 12 months from the date your disability began , as long as premium payments are made on your behalf; and
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b) while you are on an approved leave of absence (except a leave of absence to ente r military or naval service), your e mpl oy me nt will be d eem ed t o co ntin ue, as lon g as premium payments are made, for up to 12 months. unless you r Employer cancels you r insur ance befo re the end of that time;
2. On the date you cease to be an Eligible Employee; 3. On the last day of the calendar month following the last month in
which a premium payment is made; 4. On the date such coverage is terminated for any reason; 5. On the date such coverage is terminated for all Employees; or
6. On the date the policy terminates.
TermInation of Dependents Coverage Only
The DENTAL EXPENSE BENEFITS coverage for your Dependent s only will automatically cease before your Employee Insurance on the earliest of: 1. Th e date you fai l to mak e any required contribution for such
Dependents Coverage;
2. Th e date such Dependents Coverage is terminated fo r any reason; or
3. The date a person ceases to be a Dependent as defined in the policy. but only with respect to such person.
PART 9: TE~r<a~~~~f8~TINUATION
Covered Employees and Dependents may be eligible for Temporary Continuation of coverage under certain qualifying events.
Qualifying Events
1. If a covered Employee resigns, retires, or otherwi se terminates employment (except for reasons of gross misconduct) or ceases to be elig ible beca use of reduced hours or who se approved le ave without pay exp ir e s , the Employe e or a qu a lifi ed benefi ciary may elect to continu e coverage for the Employee a nd any cov ere d eligibl e De pend ents for a peri od of up to eighteen (18) month s, subject to the limitati ons outlined in this Section. -36-

2. A covered spouse upon the death of the Employee, divorce, or legal separation from the Employee may elect to continue coverage for the spouse and Dependent Children for a period of up to thirty six (36) months, subject to the limitations outlined in this Section. Dependent Children shall not be covered by a spouse under the Temporary Continuation Provision and the Employee's contract.
3. A covered Dependent Child upon the death of the Employee or attainment of age 19 (age 26 if a full time student) may elect to continue coverage for a period of up to thirty six (36) months, subject to the limitation outlined in this Section. An election by the spouse under Item 2 shall be the election on behalf of minor Dependent Children.
4. A covered Dependent may continue coverage for the maximum of thirty six (36) months if events listed in Items 2 or 3 occur during the eighteen month period following the Employee's employment termination under Item 1. The thirty six (36) months shall be inclusive of any period in which coverage was continued following the Employee's employment termination.
5. An active Employee who has made application for disability or service retirement and who may be eligible for retirement shall be eligible to extend coverage.
6. If a covered Employee retires without receiving a sufficient retirement benefit or if the retired Employee's retirement benefit becomes insufficient to pay the dental deduction amount, the retiree will be permitted to continue the dental option under the Temporary Continuation Provision.
7. Coverage may be extended for an additional eleven (11) months for an extended beneficiary who at any time during the first sixty (60) days of the 18 month COBRA continuation period meets the Social Security definition of disability . Such disability shall be determined under Title II or Title XVI of the Social Security Act. The eleven (11) additional months of coverage applies to the disabled beneficiary and to non-disabled Dependents who are entitled to COBRA. To be eligible for the additional extension, the beneficiary must notify the Flexible Benefits Program of the determination by the end of the 18 month COBRA coverage continuation period.
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Termination of Continuation Coverage
Dental Expense Benefits for a person who elects to cont inue coverage unde r this provision sha ll terminate on the earliest of the following dates: 1. The maximum time period allowed by the qualifying event; 2. Term ination of this Plan by the Employer; 3. Failure by the Covered Person to pay the initial prem ium under
these Temporary Cont inuation of Coverage provisions with in 45 days following acceptance by the Co ver ed Person under this pro vision; 4. Failure by the Covered Person to pay subsequent prem iums with in the 30 day grace period fo llowing the month for which coverage has been paid; or 5. The date the Covered Person becomes covered under another group plan.
Noti ce
Notice of a Request for continued coverage as a divorced or legally separated spouse or Dependent Chi ld is contingent upon the Employee notifying the Flex ib le Benefits Program within sixty (60) days of the divorce or legal separation from the spouse or attainment of the Dependent Child 's age of majority. Notice of the Employee's elig ibility upon employment termination or the Covered Dependent's e ligibility upon t he Employee's death shall be provided by t he employ ing Department. If coverage is to be co ntinued , the Co vered Person (s) mus t file the election form with the Flexible Benefits Program within sixty (60) days of the notice from the Employer or Department.
Premium
A co ve red perso n who elects contin uatio n coverage sha ll make payme nt of the premium no t in excess of 102% of the applicable premiu m in accordance with instructions provided by the Employer.
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PART 10: RETIREE AND SURVIVING SPOUSE/DEPENDENT CONT INUATION
OF COVERAGE
Employees who are elig ible to participate and were enrol led in the de nta l option at the t ime of retirement on or after Ap ril 1. 1997, may be elig ible for cont inu ing their denta l coverage through their retirement annuity .
Retired Employee means an employee who:
a) was enrol led under the Flexible Benefits Program dental plan with continuous coverage on or after April 1, 1997; and
b) is eligible to rece ive an immediate and sufficient mo nthly benefit from the Emp loyees' Retirement System , Legislative Retireme nt System , Teache rs Retirement System , Public School Emp loyees ' Ret ire me nt System , Superior Co urt Judges Retirement System, or District Attorney's Ret irement Sy stem ; and
c) elects to participate in the Flexible Benef its Program dental plan as a retiree under one of the above retirement system s.
Surviving Spouse/Dependent means someone who:
a) was co vered as a Depe ndent by an active or Retired Employee under the Flexible Benefits Program denta l plan; and
b) is eligible as a beneficiary of the active or Retired Employee for an immediate and sufficient monthly benefit from the Employees' Ret irement Sys te m, Legislati ve Ret ire ment System, Teachers Retirement System, Public School Employees' Retirement System , Superior Court Judges Retirement System, or District Attorney's Retirement System; and
c) elects to participate in the Flex ible Benefits Program dental plan as a Surv iving SpouselDepende nt un der o ne o f the abo ve retirement syste ms; and
d) is not ot herwise eligib le to partic ipate in the Fle xib le Benefits Progra m dental plan as an acti ve Employee, or as a Dependent Child covered under another act ive Employee, or is eligib le as an active Employee .
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Eli g i b i l i t y
To be elig ible to enroll in the dental plan as a Retired Employee or Surv iving Spouse/ Depen dent, you must meet the defin ition of a Retired Employee or Surviving SpouselOependent, and have continuous coverage (with no lapse in coverage) under the Flexible Benefits Program dental plan . In additio n, a Flexible Benefits Program "Retiree/Su rviving Spouse Enrollment Form for Dental Coverage" must be co mple ted to authorize deductions fo r dental coverage by the Employee's applicabfe retirement system.
A Retired Employee or Surviving Spouse/Dependent will be subject to ce rtai n Term s and Con ditions not ap plica ble t o a n active Employee. such as no t having an annual Open Enrollm ent Per iod. However. upon the initial e nroll men t as a Retired Employee or Surviving Spouse/Dependent, the following changes are allowed:
1. Change of Dental Option. A change of option means a change between Preferred Prov ider Org anization (PPO ) and regu lar dental insurance coverage.
a) at the time of enro llmen t, a change may be made to the PPO option or Traditional option. To enroll in a PPO option,
a person must live in the metropolitan Ananta. Augusta , or
Savannah areas, or have a PPO available in their area.
b) if a person moves from a PPO area, a change tro m th e PPO option to the regular d ental insurance option is permitted. However , once a change is made, reenrollment in the PPO option is not permitted.
2. Change o f Dental Coverage Type. A change of dental coverage type means a change betw een Single and Family coverage. The following changes are allowed:
a) a change from Family to Single dental coverage is allowed upon request.
b) retirees are allowed to change from Single to Family dental cov e rage upon acq uisition of a Dependent by marriage, birth, adoption, or for certain other changes in family status, provided the requ est and documentation is fil ed no later th an 31 da y s f o llo w i ng the e vent. S urv iv i ng Spouses/ Dependents cannot change from Single to Family dental coverage.
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A sur viving spouse of a decea sed Employee enrolled in the dental plan ma y elect dental coverage as a Surviving Spo use, or if the sp ouse is an active Employee , through pa yroll reduct ion. The surviving spouse cannot elect dual coverage under this plan.
Upon the death of an active or retired Employee, a surviving eligible Dependent Child who was covered under the family dental plan and is the principa l benefi ciary under one of the retirement systems may continue coverage, until such time they no longer meet the eligibility requ irements. The Dependent Child may not be covered under the reti ree dental pro vis ion , if co vered as a Dependent Child under a nothe r active or retired Emp loyee, or is eligible as an active Employee.
A Surviving Spouse/Dependent will be eligible fo r dental deductions only if this person is receiving an immediate and suff icient benefit from an elig ible retirement system. If the annuity is insufficient , the Surviving Spouse/Dependent will be eligible for continuing coverage under the "Temporary Coverage Continuation" under PART 9 of this certificate.
PART 11: GENERAL PROVISIONS
The Policy and Application
The group policy issued to the Policyh older , together wit h the application of the Policyholder, is the entire contract between Phoenix Home Life and the Policyholder. All statements that the Policyholder, the Empl oyer, or you, the Emp loyee, make are deemed to be representations and not warranties. No written statement signed by you will be used in any legal action against you unless Phoenix Home Life gives you or your representative a copy.
Changes To The Policy
Phoenix Home Life and the Policyholder can change the policy in its entirety or with respect to any or all class or classes of Employees at any time if Phoenix Home Life and the Policyholder agree in writing to make such a change . Any such change will be valid without the consent of any person other than the Policyholder and Phoenix Home Life.
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All such changes will be signed by Phoenix Home Life's President, Vice President, Secretary or Treasurer and countersigned by one of Phoenix Home Life's registrars or Phoenix Home Life's President , Vice President, Secretary or Treasurer. No agent may change or waive any of the polic y pro vis ions; nor can an agent make any agreement that would be binding on Phoenix Home Life.
Waiver of Policy Provision
If at some time Pho enix Home Life chooses to wai ve a policy provision , Phoenix Home Life still retains the right to enforce that provision at any other time. To be effective. such waiver must be in writing and signed by a person who is authorized by Phoenix Home Life to waive such terms.
Clerical Error
Cler ical errors in connection with the policy or de lays in keeping re cords for the policy w heth er by Phoen ix Home Life or the Policyholder: 1. Will not term inate insurance that would other wise have been
effective.
2. Will not continue insurance that would otherwise have ceased or should not have been in effect.
If appropriate, a fair adjustment of premium (or claim payment) will be made to correct the error.
Misstatemen t of Facts
If relevant facts about any Employer or Employee relat ing to this insurance are not accurate: 1. If appropriate, a fair adjustment of premium will be made.
2. The true facts will decide whether, and in what amount, and for what duration insurance is valid under the policy.
Notice
Any obligation for which Phoenix Home Life may have to give written notice will be satisfied by sending such notice to the last known address of the person or institution entitled to such notice.
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Disch arge of Our Responsibility
Payment made under the terms of any sec tion of the poli cy will . to the extent of such payment . release Phoenix Home Life from all further obligatio ns under the policy. Phoenix Home Life will not be obligated to see: to the ap plication of such payment.
Reimbursement
Reimbu rsement wil l be mad e to Phoe nix Home Lif e for any overpaym ents that Pho enix Home Life ma y make due to any reason. Dedu cti ons ma y be ma de fr om f uture ben efi t pa ym ents to recover any such overpay ments . If Phoen ix Home Life ha s rei mburse d you for all or part of a pay ment which you or a Covered Dependent , if any, were entitled to reco ver from a third party , you or such Dependent must repay Phoeni x Home Life at that time . Such payment must be to the extent that Phoenix Home Life has reimbursed you or such Dependent, regardl ess of whether your coverage or that of such Depe ndent is still in force on the da te Phoen ix Home Life recovers such amou nt from you or such dependent.
Pro ofs of Claim
To aid in the determination of benefits payable, you will be required to submit all denta l claims on forms satisfactory to Phoeni x Home Life within 90 days of the Incurred Date of the dental t reatment. Also , Phoenix Home Lite has the right to require any of the following : 1. A complete dental chart showing:
a) extractions; b) missing teeth; c) fillings; d) prostheses; e) periodontal pocket depths; and f) the date of any work previously performed; g) for orthodontia:
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i) Full Mouth Dental X-Rays; ii) Cephalometric X-rays and Analysis; iii) Study Models;
iv) Completion of a brief questionnaire which will specify: a) the degree of overjet, overbite , crowding , open bite ;
b) if the t ee t h ar e impacted in cro ssb ite , or congentially missing;
c) the length of treatment; and
d) the total charge for the treatment.
2. An itemized bill for all dental care.
3. The following exhibits:
a) x-rays; b) study models; c) laboratory andlor hospital records. 4. A dental ex amination at Phoeni x Home Life' s expen se by a Dentist whom Phoenix Home Life may choose. 5. Any addit ional inform ati on Phoeni x Home Life may nee d to process your claim.
Physical Examination and Autopsy
Except as otherwise provided in the policy, Phoenix Home Life has the right to have you or your Depende nt examined as often as is reasonably necessary following the receipt of a claim and while a claim is pending, or while any payments are being made under the policy. Approval of claim for benefits and the continuation of benefits are subject to your or your Dependent's cooperation in submitting to such examination. In the case of death, Phoenix Home Life also has the right to require an autopsy as long as the law does not forbid it.
Legal Actions
For 60 days after written Proof of claim has been filed, as required by Phoeni x Home Life, no legal or equitable action may be brought against Phoenix Home Life for that claim. No action at all may be brought against Phoenix Home Life after 3 years from the date on which written Proof of claim is required.
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Assignment
You cannot assign any interest in the polley unless Phoenix Home Life agrees in writ ing to such an assignment. Phoenix Home Life has the right to determine the extent to which any assignment will be honored and the priority of such assignment. Phoenix Home Life does not assume any responsibility for the validity or sufficiency of any ass ignment. Any payments made under such assignment after consented to by Phoenix Home Life will discharge Phoenix Home Life's liabilities under the policy, to the extent of such payments.
Workers' Com pensation
This insurance does not take the place of or affect any requirement for coverage by Workers' Compensation Insurance.
Facil ity of Payment
Phoen ix Home Life will pay you all benefits , if your Proof of claim is
satisfactory to Phoenix Home Life, except in the following situations:
1. You are a minor. In such case, claim may be made by your duly appointed guardian, conservator or committee and Phoen ix Home Life will pay to such person or persons; or
2. Due to physical or mental incapacity, you cannot, in Phoenix Home Life's judgment, give Phoen ix Home Life a valid receipt for payments. In such case, claim may be made as described in item 1; or
3. You die before Phoen ix Home Life pays you. In such case, claim may be made by your executor or the administrator of your estate and Phoenix Home Life will pay to such person or persons.
If Phoenix Home Life does not pay you and claim is not made by the appropriate person designated above, Phoenix Home Life may, at
our opt ion , make payments under either or both Methods A or B
below. Any decision to pay any benefits, prior to the appointment of the appropriate person designated in items 1, 2 or 3 above, is solely at Phoenix Home Life's discretion, and Phoenix Home Life may choose to pay no amounts under any circumstances until such appropriate person is formally appointed.
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Method A: Phoenix Home Ufe may pay the whole or any part of such benefit to any institution or person on whose charges payment of the benefit is based toward the satisfaction of those charges. Method B: Phoenix Home Lite may pay the whole or any part of such benefit: 1. To your lawful spouse, up to a cumulative amount of $1,500; or 2. If you have no lawful spouse, up to a cumulative amount of $750
to anyone or more of th e foll owing rel atives in the following order of priority: a) your child or children; or
b) your mother or father.
Ti me Peri ods
All time periods referred to in the policy will begin and end at 12:01 A.M. standard time at the Employer's home office.
PART 12: HOW TO FILE A CLAIM
Pre-determination of Benefits
When the estimated cost of a recommended DENTAL TREATMENT PLAN exceeds $500, the DENTAL T REATMENT PLAN must be su bmitted to Phoe nix Home Life for its re view bef ore treatment begins. Be fo re Orthod onti c Treatment beg ins an ORTHOD ONTI C TREATMENT PLAN must be submitted to Phoenix Home Life for its review. Phoe nix Hom e ur e will send notificat ion of the benefits payab le based upon the DENTAL OR ORTHODO NTIC TREATME NT PLAN. Use the regular dental claim form for submission of pre-determined benefits.
Completing a Claim Form
Get a claim form from your Department personnel/payroll office or the Flexible Benefit Program.
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Complete the form according to the instructions on the form. Include the entire account number as it is printed on your DentalInsurance 10 card (this is NO T yo ur Soc ia l Secur ity Number). Add iti ona l instructions are available from your personnel/payroll office. You may also contac t Phoe nix Home Life for instr uctions and/or questions about your claim at
1-800-451 -2513
Send (or have your dentist send) the completed claim form directly to:
Phoenix Home Life Mutual Insurance Company Group Dental Benefits P.O. Box 1477 Greenfield, MA 01302
Appeals
In accordance with the Employee Retirement Income Security Act of 197 4 (ER ISA), if you have any questio ns or disagree with the determination of a claim you may ask to have it reviewed within 60 days. Please state yo ur reasons for disagreement in writing and include all supporti ng information to support your belief. You will be notified of a decision within 60 days. Special circumstances may take up to 120 days. Please address your letter to Phoenix Home Life Mutua l Insura nce Compa ny , Benef its Divi si on and box num ber indicated below:
Benefits Supervisor, Dental Phoenix Home Life Mutual Insurance Company P.O. Box 1477 Greenfield, MA 01302-1477
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PART 13: FREQUENTLY ASKED QUESTIONS
Q: Who is elig ible?
A: Employee Dental Insurance
Each Employee listed below is eligible for dental coverage:
1. A full-time Employee of the State of Georgia, or a State age ncy who works at least 30 h our s a week, on a continuous basis, and whose employment is expected to last at least nine (9) months;
2. A pub lic school teacher who is employed in a professionally certificated capacity, works half-time or more and Is not
considered a 'temporary" or "emergency" employee;
3. An Employee of a local school system who holds a noncerti ficated positi on and who is eligible to participate in the Teachers Retirement Syste m or its local equiva lent and wo rk ing at le ast 18 hours a week (or 60% of the ti me necessary to carry out the duties of the pos ition if that's more than 18 hours); or
4. An Emp loyee who is eligible to participate in the Public School Employee Retirement System as defined by Paragraph 20 of Section 47-4-2 of the Official Code of Georgia, Annotated and who works at least 18 hours a week (or 60% of the time necessary to carry out the duties of the position) .
For more infor mation, please refer to the defi nition of "Eligible Employee" in PART 2: DEFINITIONS of this booklet.
Dependent Insurance
You may elect to cover yo ur eligible depend ents . Eligible dependents include your:
spouse;
u nma rried children under age 19 (or full -tim e st udents unde r age 26) who are depende nt upon you for at least 50% of their support; or
Handicapped Child as defined on page 10.
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Q: Wh en does coverage begin for new employees who enro ll when first eligible?
A: If you enroll for eithe r the Traditi onal Opti on or the PPO Option when you are first eli gible , your coverage will beco me effective as follows:
1. You (and your eligible dependents) will be eligible for Type I and II expe nses on the first day of the calendar month after completing one (1) full month of employment;
2. You (and your eligible dependents) will be eligible for Type III and IV expenses on the first day of the month following six (6) months of coverage;
For more information, please refer to PART 3: EMPLOYEE AND DEPENDENT COVERAGE ELIGIBILITY..
Q: What happens if I don't enroll when I first become eligible?
A: If yo u do not enro ll for Denta l ins urance whe n yo u are firs t eligible , you will be co nsidered a Late Entrant with respect to Employee Insurance and will be subject to the Limitation on Late Entrants section.
For mor e inf orm ati on, please refer to the Limi t ati on on Late Entrants section on page 16.
Q: What are covered expenses?
A: Under the Traditional Option, a cove red expense is the lesser of th e us ua l or custo ma ry charge . Unde r the PPO Opti on , a cov ered expe nse is the lesser of the custo mary or sched ule charge.
Usual and customa ry charges are the normal charges made by the prov ider for similar serv ices that do not exceed the normal charges made by most providers in the locality where the service is re cei v ed. T he na t ure a nd seve r ity of t he cond itio n is considered. Schedu le charges are pre-determi ned fees charged and recei ved for a give n service by the Dentist's office in the area where the scheduled charge for such service is made.
For more info rm ation on covered expe nses, please refe r to PA RT 1: INSURANCE SC HE DULE and PART 5: COVERED EXPENSES.
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Q: If I am enrolled as a PPO participant and my PPO Pro vider refers me to a spec ia list how does t hat affect my benef it payment?
A: As k yo ur PPO Provider if t he specia list is part of the PPO Network. If unknown, contact Phoenix Home Life through our toll f ree number to verify me mbership. If t he pro vider is not in the network, refer to the PPO Provider Directory for a li sting of Prov iders and Specialists. If you choose a Prov ider outs ide the network, Phoen ix Home Life will pay the Provider at a rate equal to what the PPO Dentist wo uld have been paid. The non-PPO Dentist is entitled to collect from you the difference between the amou nt of bene fits payable b y Phoenix Home li fe and the provider's Usual Charge .
Q: Who covers Scali ng and Root Plani ng, my dental in surance or my medical insurance?
A: If the Sca ling and Root Planing is being done in conjunction with surgery and you are enrolled under th e State Healt h Benefit Plan Standard or High option, first subm it your claim to the State Hea lth Benefit Plan. If State Health does not cover the Scaling and Root Planing, subm it to Phoenix Home Life. If the Sca ling and Root Pla ning is done as a separate procedure, submit to Phoenix Home Ute.
C: I had dental work perfo rmed in Janu ary and was fitt ed with a covered temporary part ial denture. Benefits were provided for the temporary part ial. It is now May of the same calendar year and I'm sti ll wa iti ng for t he p erm an ent re placement partia l to be constructed. In orde r for benefits to be payab le u nder the te mpora ry w o rk benef it , ho w l o n g do I h av e befo re the temporary partial is conside red permanent?
A: A temporary prosthetic is cons idered permanent after 12 months fro m the incurred date. In thi s sit uatio n, the permanent par tial must be inc urred and placed prio r to January of the fol lowing year. As of January of the follo wing year, the temporary partial will be considered perma nent and replacement will be subject to the prosthetic freque ncy limitation.
For m o r e informa t ion, p lease refer to PART 4 : DETERM INATION OF BENEF ITS.
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Q: What does Coord ination of Benefits m ean? A: If you o r your covered dependents a re eligible to receive
benefits under another group plan , benefits from this plan will be coo rdinated wit h the benefits from any of your other group plans so that up to 100% of the Allowable Expe nses incurred during a cale ndar year will be paid jointly by the pla ns. In orde r to obtain all of the benefits ava ilable , yo u and your cove red dependent s sh ould fi le cla ims under each plan . Als o , each in su rance company shoul d be advised about the other group coverage at the time you or your covered depend ents file a claim.
0 : How are benefits coordinated if a parent with custody of the
child has not rem arried? A: The pla n that covers the child as a dependent of a paren t wi th
custody will pa y its benefits befo re the plan that covers the child as a dependent of a parent without custody. (e.g. Our (phoenix) ins ured 's ex-spouse has no t remarried and has custody of the child. T h e e x-spouse's in suranc e co m pa ny wo uld b e t he pr imary carrier, Phoeni x woul d be th e secondary ca rrier. If the ex-spouse has no insu rance co ve rage, Phoeni x would be th e primary carrier). For more information , please refer to PART 7: COORD INATION OF BENEF ITS.
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Underwritt en By Phoen ix
Hartford , Connecticut
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Administered By Georgia State Merit System
Personnel Administration Atlanta, Georgi a
Georgia M erit
Sys te m
People . Pa rtn ersh ips Perfo rm an c6