Dental Care Plan Summary

Important Information

The information in this document is a summary of the major provisions of this benefit plan, and constitutes the summary plan description as governed by the Employee Retirement Income Security Act of 1974 (ERISA). Benefits under the plan are determined by the terms of the underlying plan document and contracts. In the case of any inconsistency between this document and the plan document or contract, the plan document or contract will govern your rights and benefits.

RIT intends to continue the benefit plans indefinitely, but reserves the right to modify or terminate all or any portion of the employee benefits package at any time with or without notice. Such changes automatically will apply to you and your employment relationship at RIT. Participation in this plan is provided to eligible employees and does not constitute a guarantee of employment, requires continued employment and eligibility and is subject to the terms and conditions of the underlying plan document and insurance contracts.

Table of Contents

Plan Number: 505
Plan Year: 1/1 - 12/31
Plan Established: 07/01/1981

Key Features of the Dental Plan

Preventive Care

Covered expenses include:

  • cleanings
  • examinations
  • fluoride treatment examinations
  • diagnosis
  • x-rays

Provides 100% coverage with no deductible requirement, subject to reasonable & customary charges.

Basic Restorative Care

Covered expenses include:

  • fillings
  • extractions
  • periodontal treatment
  • root canals

Pays 80%, subject to the annual deductible and maximum benefit, subject to reasonable & customary charges.

Major Restorative Care

Covered expenses include:

  • crowns
  • bridges
  • dentures

Pays 50%, subject to the annual deductible and maximum benefit, subject to reasonable & customary charges.

Annual Deductible

Individual - $25
Family - $50

Annual Maximum Benefit

$1,000 per Person

There is no deductible or annual maximum benefit for preventive care. Preventive care and orthodontic expenses do not count toward the annual maximum benefit.

Orthodontics

Covers 50%, up to a $1,000 lifetime maximum, for dependent children under age 19. Annual deductible and annual maximum benefit above does not apply to orthodontics.

Introduction

The RIT Dental Care Plan covers most dental services, with a $1,000 annual maximum. This handbook addresses important topics such as eligibility, changing your election, appealing the denial of a claim, and what happens when your coverage ends. In addition, this handbook describes the benefit provisions of the RIT Dental Care Plan, which is a self-funded plan administered by Excellus BlueCross BlueShield.

General Information

Who is Covered and When

Regular full-time and extended part-time employees are eligible to participate in the Dental Plan. If you elect dental coverage, it can begin on the first day of the month on or after your date of employment. You need to enroll, however, and authorize the payroll deductions to pay your share of the cost before coverage can begin. If you are not at work on the day coverage is supposed to start, coverage will become effective on the day you return to active employment.

You also may obtain coverage for your spouse or domestic partner and/or eligible children by enrolling in two person or family coverage and authorizing payroll deductions to pay your share of the cost. You may not cover your spouse/domestic partner as a dependent if your spouse is enrolled for coverage as an employee. No dependent child may be covered by more than one employee in the plan. No dependent child can be covered as both an employee and a dependent.

Please refer to the Domestic Partner section of this handbook for more information on covering a domestic partner.

The eligibility rules for children are as follows:

The natural or adopted child of the employee or the employee’s opposite gender legal spouse

  • who is under age 26, and
  • who does not have access to employer-sponsored coverage from someone other than a parent.

 

The natural or adopted child of the employee’s domestic partner or same gender spouse*

  • who is under age 26, and
  • who does not have access to employer-sponsored coverage from someone other than a parent.
  •  
  • *if the child is not claimed as a depending on the employee’s federal income tax return, this benefit will be taxable.

 

Any other child

  • who is under age 26, and
  • for whom the employee is the legal guardian, and
  • who resides in the employee’s home, and
  • who is claimed as a tax dependent on the employee’s federal income tax return, and
  • who does not have access to employer-sponsored coverage from someone other than a parent.

 

Coverage for an unmarried dependent child who is physically or mentally disabled may be continued beyond the age limits of the Plan. Contact the Human Resources Department for further details.

Coverage for your dependents usually begins when your coverage begins. However, if your spouse/partner or a dependent child is confined in an institution or at home for medical reasons when coverage is supposed to begin, coverage will become effective on the first day the person is no longer confined.

A spouse/partner who is divorced from you is not eligible for coverage under the Plan. If you have an eligible dependent who is also an RIT employee, he or she may be covered either as an employee or as a dependent, but not both.

You Need to Enroll

Dental Plan coverage is not automatic; you need to complete an enrollment form for coverage to take effect. On the form you indicate your election of dental coverage, and whether you want individual, two person, or family coverage.

It is important for you to return the completed enrollment form within 30 days after you first become eligible for coverage. If you wait beyond 30 days to enroll, you will not have another opportunity to enroll until the Plan's next open enrollment.

Open Enrollment

Because dental care needs change from time to time, you have the opportunity once each year – effective as of January 1 - to make a change in your dental plan election. You can enroll in or cancel coverage or change your coverage level (i.e., change from individual to two person). If you do not make a change during an open enrollment period, you will have to wait until the next open enrollment period to make a change unless you experience a qualified change in status that permits changes in your election. Information regarding qualified change in status events is found in the Medical Plan section of this handbook.

Election Changes During the Plan Year

In general, once you have enrolled in the Plan, you cannot change your elections or withdraw from the Plan until the beginning of the next plan year. However, pursuant to federal regulations, you may be able to make mid-year election changes if you meet certain criteria, as explained in the Election Changes During the Plan Year section of the Medical Care Plan section of this handbook. Your requested election change must be consistent with the reason for the change. For example, it would be consistent for an employee with two-person coverage that adopts a child during the year to change his or her election to family coverage. It would not be consistent to move from a family contract to a single contract. Changes must be made within 31 days of the event that gives you the right to make a new election. The Administrator may require you to submit certain documentation related to your reason for making a mid-year election change. New elections will become effective as soon as administratively possible.

For more details on mid-year changes, please refer to the Medical Care Plan section of this handbook.

Who Pays For This Protection

You and RIT share the cost of your dental plan. Your share of the cost will be based on whether you choose individual, two person or family coverage. Claims under the RIT Dental Care Plan are paid from the general assets of RIT under a self-funded arrangement, which is administered by Excellus BlueCross BlueShield.

Rates for dental coverage are provided annually by the Human Resources Department. These rates are subject to change. You will be notified in the event of any change in rates.

Coordination of Benefits

If you have dental coverage under another group plan in addition to this one - through that of a spouse/partner, for example - the total benefits you are eligible to receive could be greater than your actual expenses. To help eliminate this duplicate spending, our Plan's coverage is coordinated with other group plans with which you have coverage. This means that when the RIT Plan pays second, benefits will be adjusted so that the total payments from both plans won't be more than 100% of total covered charges.

For your own claims and those of your spouse/partner, the plan that pays first is the one that covers you, your spouse or partner as an employee. If your children are covered by more than one plan, the plan of the parent whose birthday occurs earliest in the year will pay benefits first. However, if you are separated or divorced, the plan of the parent who has financial responsibility for the child's medical care expenses will pay first. If there is no court decree for medical care coverage, then the plan of the parent who has custody of the child will pay first. Where none of these situations apply, the plan that you're covered under the longest will pay first.

When Coverage Ends

Your dental coverage ends the last day of the month in which

  • Your employment ends*;
  • Your employment ends under the RIT Severance Plan (coverage does not continue during the severance period, unless you elect coverage under COBRA);
  • You retire; if you are eligible for retiree medical coverage, coverage can continue under the retiree medical plan;
  • You no longer meet the Plan’s eligibility requirements; this includes transfer to an employment category that is not eligible for coverage under the Plan, such as part-time employees and adjunct faculty;
  • You stop making required contributions;
  • You die; or
  • RIT discontinues the Plan.

* Special Note for 9½ month faculty:

  • Coverage will end on June 30 for a faculty member on a 9½-month contract , provided that the faculty member works until the end of the contract period, and the contract is not being renewed for the following academic year;
  • Coverage for a faculty member on a 9½-month contract will continue during the summer between the two academic years, provided that the contract is being renewed for the following academic year.

Generally, your dependent's coverage ends when your coverage ends. However, a dependent's coverage also will end on the last day of the month in which;

  • He or she no longer meets the Plan's dependent eligibility requirements ; or
  • You stop making required contributions.

If you or a dependent submit a fraudulent claim under a medical or dental plan, you and all your dependents will be permanently ineligible for coverage under all RIT medical options and the RIT Dental Care Plan.

The active dental plan ceases upon retirement. As a retiree, you can choose to continue coverage for 18 months under COBRA (Consolidated Omnibus Budget Reconciliation Act) by paying the total premium plus a 2% administrative charge to the Dental Plan Administrator directly. See the Medical Care Plan section of this handbook for information on COBRA continuation of coverage. There is no conversion option under this plan.

Coverage May Be Continued

In certain circumstances, your coverage and that of your dependents may be continued beyond the date it normally would end. Coverage may continue as shown below, provided you make any required premium contributions.

  • For a Disabled Child - Coverage for an unmarried child who is physically or mentally incapable of self-support may be continued beyond the age limit of the plan provided the disability occurred before that age and family coverage was in effect before the disability occurred.
  • For a Personal Leave of Absence - Coverage may continue while on a personal leave of absence of up to three months. For leaves of absence beyond three months, coverage is not continued.
  • For a Professional Leave of Absence (including sabbaticals)- Coverage is continued for up to two years while on an approved professional leave of absence, including a sabbatical.
  • For Long-Term Disability - Coverage is continued during long term disability in the same manner as it was during active employment. Coverage will end when benefits under RIT's long term disability plan end.

When You Are Eligible for COBRA

See the Medical Care Plan section of this handbook for information on COBRA continuation of coverage. There is no conversion option under this Plan.

What the Dental Plan Covers

Preventive Services

You can minimize the risk of more serious and costly dental treatment by having regular examinations. To encourage this, the Dental Plan pays 100% of reasonable and customary charges for examinations, x-rays and other preventive measures.

Preventive services include:

  • Cleaning of teeth, every six months;
  • Oral examinations, every six months;
  • Fluoride treatment;
  • Sealants on 1st and 2nd permanent molars, up to age 16, once in three years;
  • Diagnosis;
  • Full mouth x-rays once every 36 months, unless needed more frequently because of anticipated periodontal work, possible orthodontic work, or a change of dentist.

The Dental Deductible

Benefits for Basic and Major restorative services are subject to an annual dental deductible. The amount of the deductible for each covered person is $25 per calendar year or $50 per family (if you have enrolled your dependents).

Basic and Major Restorative Services

The Plan also helps you pay for necessary restorative services recommended by your dentist. Once the deductible is satisfied, the Plan pays 50% of reasonable and customary charges for basic and major restorative services.

Basic restorative services include:

  • Extractions
  • Fillings
  • Periodontal treatment
  • Root canals

Major restorative services include:

  • crowns
  • bridgework
  • dentures

Annual Maximum Benefit

For basic and major restorative services, there is an annual maximum benefit of $1,000. This annual maximum applies separately for you and each covered family member.

Orthodontics

The Plan covers orthodontics treatment for dependent children under 19 years of age.

Covered orthodontic services include the following:

  • Initial insertion of orthodontic appliances, as well as any subsequent insertions;
  • Orthodontic treatment before and after appliances are inserted to correct malocclusion;
  • Space maintainers and other corrective appliances;
  • TMJ therapy.

Orthodontic Lifetime Maximum

There is a $1,000 lifetime maximum per covered family member for orthodontic expenses. This lifetime maximum is not part of the annual maximum for restorative care.

Limitations

All covered procedures are subject to an alternate benefit allowance. Where there is more than one technique or material type for a dental procedure, the dental plan will reimburse for the procedure which has a lesser allowance. When alternate benefit is enforced, the subscriber's benefits are not intended to interfere with the treatment plan recommended by the dentist. The subscriber and dentist should discuss which treatment is best suited for the patient, and may proceed with the original treatment plan regardless of the benefit determination. If the more expensive treatment is chosen, the subscriber is liable for the balance up to the billed amount.

In the event of a treatment by more than one dentist, the plan will not pay more than it would have if one dentist had performed the entire service.

Reimbursement will be based on the Blue Shield Schedule of Allowances.

Exclusions

The Dental Plan does not cover:

  1. A service furnished an individual for:
    1. Cosmetic purposes unless necessitated as a result of accidental injuries sustained while such individual was insured under this benefit, and for the repair of which the service is furnished within one year of the date of the accident and while the individual remains covered under this benefit. For purposes of this limitation, facings, or crowns, or pontics, posterior to the second bicuspid and the personalization and characterizations of dentures shall always be considered cosmetic.
    2. Dental care of a congenital or developmental malformation.
  2. Replacement of lost, missing, or stolen prosthetic device, or any other device or appliance.
  3. Appliances, restorations, or procedures for the purpose of altering vertical dimension, restoring or maintaining occlusion, splinting, or replacing tooth structure lost as a result of abrasion or attrition, or treatment of disturbances of the temporomandibular joint.
  4. A service not furnished by a dentist, unless the service is performed by a licensed dentist hygienist under the supervision of a dentist or is an x-ray by a dentist.
  5. A service not reasonably necessary, or not customarily performed, for the dental care of the individual.
  6. Charges for oral hygiene, a plaque control program, or dietary instruction.
  7. Charges for implantology.
  8. A service furnished by or on behalf of any government, unless as to such government, payment of a charge for such service is legally required, or charge for any dental services to the extent that benefits are payable therefore, under any law government program under which an individual is or could be covered. The term any government includes the federal, state provincial, or local government or any political subdivision thereof of the United States or any other country.
  9. The replacement of any prosthetic appliance, crown, inlay or onlay restoration or fixed bridge within five years of the date of the last placement of such appliance, crown, inlay, onlay restoration or fixed bridge unless such replacement is required as a result of accidental bodily injury sustained while the covered individual is insured under its benefit.
  10. Dental care or treatment when such services are rendered to an individual by his/her spouse, child, brother, sister, parent or parent of such person's spouse.

Your Rights under ERISA

[The U.S. Department of Labor requires that the following notice be included in all Summary Plan Descriptions.]

As a participant in Rochester Institute of Technology benefit plans, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:

Receive Information About Your Plan and Benefits

Examine, without charge, at the plan administrator's office and at other specified locations, such as worksites, all documents governing the plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.

Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

Receive a summary of the Plan's annual report. The Plan Administrator is required by law to furnish each Participant with a copy of this summary financial report.

Continue Group Health Care Coverage

Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights.

Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. [NOTE: None of the health insurance options presently offered by RIT include a pre-existing condition exclusion.]

Prudent Actions by Plan Fiduciaries

In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "Fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your Questions

If you have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

Qualified Medical Child Support Orders ("QMCSOS")

A medical child support order shall be filed with the plan administrator as soon as reasonably possible after it has been filed promptly upon the receipt of such order, the plan administrator shall notify the participant and each person eligible to receive benefits under the terms of the order ("alternate recipients") of its receipt and of the procedures set forth in this section 14.04.

The Participant and the alternate recipients may provide comments to the Plan Administrator with respect to the order during the 30 day period commencing as of the date the Plan Administrator sends them notice of receipt of the order. The Plan Administrator shall, within the 60 day period commencing as of the expiration of the 30 day comment period specified in the preceding sentence, determine whether the order is qualified and shall so notify the participant and the alternate recipients in writing of its decision. The parties may waive the 30 day comment period. If they do so, the 60 day period shall commence as of the date all parties have waived their rights to submit comments. The Plan Administrator's determination on the qualified status of an order is final. As soon as reasonably practicable following its notification that an order is "qualified," the Plan Administrator shall take such steps it deems appropriate to implement the order.

The Plan Administrator encourages parties to submit draft orders for "pre-approval" of their qualified status prior to their being submitted to a court for signature as such pre-approval will expedite approval procedures.

An alternate recipient may designate a representative for receipt of copies of notices that are sent to an alternate recipient with respect to a medical child support order.

Claim Procedures

  1. Claims for Benefits - An Employee wishing to present a claim for benefits for himself or his Dependents should obtain a claim form or forms from his Employer or Plan Administrator. The applicable section of such form or forms should be completed by (1) Employee, (2) Employer or Plan Administrator, and (3) attending Physician or Hospital. Claims will only be processed if received within a reasonable time following the date the expense to which the claim relates arises.

    Following completion, the claim form or forms should be submitted to the Plan's representative as indicated on the reverse side of the Employee's Benefit Plan Identification Card. The organization that is authorized by the Plan to process and pay claims (the Plan's Claims Administrator) will compute benefits due, and cause proper claims to be paid. Unless the Employee assigns benefits to a doctor or to a Hospital, draft(s) will be made payable to the Employee.

    A decision will be made by the Claims Administrator no more than ninety (90) days after receipt of due proof of loss, except in special circumstances (such as the need to obtain further information), but in no case more than one hundred eighty (180) days after the due proof of loss is received. The written decision will include specific reasons for the decisions and specific references to the Plan provisions on which the decision is based.

  2. Appealing Denial of Claims - If a claim for benefits is wholly or partially denied, notice of the decision shall be furnished to the Employee. This written decision will:
    1. Give the specific reason or reasons for denial;
    2. Make specific reference to the Plan provisions on which the denial is based;
    3. Provide a description of any additional information necessary to perfect the claim, if possible, and an explanation of why it is necessary; and
    4. Provide an explanation of the review procedure.

    On any denied claim an Employee or his representative may appeal to the Plan Administrator for a full and fair review. The claimant may:

    1. Request a review upon written application within sixty (60) days of receipt of claim denial;
    2. Review pertinent documents; and
    3. Submit issues and comments in writing.

A decision will be made by the Plan Administrator no more than sixty (60) days after receipt of the request for review, except in special circumstances (such as the need to hold a hearing), but in no case more than one hundred twenty (120) days after the request for review is received. The written decision will include specific reasons for the decision and specific references to the Plan provisions on which the decision is based.

Additional information about claims submitted and review procedures may be obtained by contacting the Plan Administrator.

If you have any questions about your Plan, you should contact the Human Resources Department. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest Area Office of the U.S. Labor Management Services Administration, Department of Labor.

Additional Information

Employer
Rochester Institute of Technology

Employer Identification Number
16-0743140

Plan Sponsor
Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604

Plan Administrator
Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604

Business Telephone Number
(585) 475-2424 (voice)

Agent for Service of Legal Process
Associate Director, Benefits, Health, and Wellness
Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604