RFP_26_041_Attachment 2_2022 Basic_DHMO_Cert.pdf

SBI-MDCOC-0-

S700B Access+ PBC

Certificate of Coverage

FOR: PBC Board of County Commissioners

DENTAL POLICY NUMBER: 13123

ENROLLING GROUP NUMBER: 13000

EFFECTIVE DATE: 01-01-2022

Administered by: Solstice Benefits, Inc.

7901 SW Sixth Court Plantation, Florida 33324

Underwritten by: Solstice Benefits, Inc.

7901 SW Sixth Court Plantation, Florida 33324

SBI-MDCOC-0-0-FL 1014

Solstice Benefits, Inc.

Dental PPO Certificate of Coverage

This Certificate of Coverage ("Certificate”) lists your rights and obligations as a Covered Person. It is important that you READ YOUR CERTIFICATE CAREFULLY and get to know its terms and conditions.

The Policy may require that you contribute to the required Premiums. You can find information regarding the Premium and your costs from the Enrolling Group.

Solstice Benefits, Inc. (“Solstice") agrees to provide Coverage for Dental Services to Covered Persons of the Enrolling Group. Dental Services are subject to the terms, conditions, exclusions and limitations of the Policy. The Policy is issued based on the Enrolling Group's application and its payment of the required Premium. The Enrolling Group's application is made part of the Policy.

The relationship between Solstice and the Enrolling Group is strictly a contractual relationship. The Enrolling Group is not an agent or employee of Solstice. Solstice and its employees are not agents or employees of the Enrolling Group.

The Policy will take effect on the date specified in the Policy. The Policy will continue in force subject to the timely payment of required Premiums and the termination provisions of the Policy. All Coverage under the Policy will begin at 12:01 a.m. local time at the Enrolling Group’s address on the date stated in the Policy.

All Coverage will end at 12:00 midnight.

The Policy is delivered in and governed by the laws of the State of Florida.

The insurance granted by this Certificate provides for DENTAL insurance only.

SOLSTICE BENEFITS, INC.

Leonard A. Weiss

President

Introduction to Your Certificate You and your Enrolled Dependents can get Coverage under the Policy if you are eligible and the required Premiums have been paid. The “Policy” referred to in this Certificate is printed on your Identification ("ID") Card.

Coverage is subject to the terms, conditions, exclusions, and limitations of the Policy. This Certificate lists the details of Coverage under the Policy but does not make up the entire Policy. You may review the entire Policy at the office of the Enrolling Group during regular business hours. This Certificate replaces and supersedes any Certificate, which Solstice may have previously issued to you. Any future Certificates issued to you by Solstice will in turn replace this Certificate.

The Enrolling Group expects to keep the Policy for the foreseeable future. The Enrolling Group reserves the right to change or end the Policy at any time. A change or end of the Policy would affect Covered Persons.

How to Use This Certificate

You should read this Certificate in its entirety. Many of the details of this Certificate and the attached Schedule of Benefits are interrelated to each other. Therefore, reading just one or two sections may not give you an accurate impression of your Coverage.

Your Certificate and Schedule of Benefits may be changed by the attachment of Riders and/or Amendments. Please read these documents to see if the provisions in this Certificate or Schedule of Benefits may have changed.

Many words used in this Certificate and Schedule of Benefits have special meanings. These words may appear capitalized and are defined for you in Section 1: Definitions. If you review Section 1, you will have a clearer understanding of the Certificate and the Schedule of Benefits.

When we use the words "we," "us," and "our" in this Certificate, we are referring to Solstice Benefits, Inc. When we use the words "you" and "your" we are referring to Covered Persons as the term is defined in Section 1.

From time to time, the Policy may be amended. When that happens, a new Certificate, Schedule of Benefits, Rider and/or Amendment will be sent to you. You should keep your Certificate and Schedule of Benefits in a safe place for your future reference.

Network and Out-of-Network Benefits

This Certificate describes both types of benefits available to you under the Policy.

Network Benefits - Dental Services provided directly by or through a Network Dentist are Network Benefits. These benefits apply when you choose to get Dental Services from a Dentist who is in the Network Dentist. The Member Copayments for Network Benefits are listed in the Schedule of Benefits for each covered Dental Service. You will generally pay less for Dental Services provided by a Network Dentist.

You must always check that the Dentist you have chosen participates in the Network prior to seeking Dental Services.

From time to time, the participation status of a Dentist may change. You can check a Dentist’s participation status by calling your Dentist, calling us, or by accessing our website. See the Contacting Solstice section below, or your ID Card, for contact information. If necessary, we can help refer you to a Network Dentist.

Out-of-Network Benefits - These benefits apply when you choose to obtain Dental Services from a Dentist who is not in the Network. The only Dental Services Covered when performed by an Out-of-Network Dentist are Preventive Services and Diagnostic Services. You must visit a Network Dentist for all other Dental Services in order to receive Coverage. The Reimbursement Amount for Out-of-Network Benefits is listed in the Schedule of Benefits. You will generally pay more for Dental Services provided by an Out-of-Network Dentist. In addition, when you obtain Covered Dental Services from an Out-of-Network Dentist, you will be required to pay the entire bill for the services received and submit a claim for reimbursement.

General - The procedures you must follow to obtain benefits from Network and Out-of-Network Dentists are listed in Section 6: Procedures for Obtaining Dental Services. The limitations described in Section 6: Procedures for Obtaining Dental Services, Section 11: Covered Dental Services, the Schedule of Benefits and the exclusions listed in Section 12: General Exclusions apply to both Network and Out-of-Network Benefits. Unless otherwise stated, the information in all other sections applies to both Network and Out-of-Network Benefits.

Dental Services Covered Under the Policy

Necessary Dental Services are the only services Covered under this Policy. A Dentist performing or prescribing a procedure or treatment for a dental disease does not mean that the procedure or treatment is Covered under the Policy. Although a procedure or treatment may be the only available treatment, it does not mean that it is Covered under the Policy.

As the law permits, we reserve the right to change, interpret, modify, withdraw, add benefits or terminate the Policy in our sole discretion. All changes or amendments to the Policy must be in writing.

We may make changes to the Policy according to the applicable laws giving at least forty-five (45) days notice to the Enrolling Group. These changes may only be made at the renewal date of the Policy.

For purposes of cost or efficiency, we may provide Coverage for services that we would otherwise not cover. The fact that we do so in any particular case will not in any way be deemed to require us to do so in other similar cases.

We may contract with persons or companies outside of Solstice to provide administrative services for your Policy.

The identity of the service providers and the nature of the services provided may be changed from time to time without prior notice to you. You must cooperate with those service providers in the performance of their duties.

From time to time, we may need more information from you to check your eligibility and your right to get Coverage for services under the Policy. You are obligated to provide the required information. Failure to cooperate may result in Coverage being delayed or denied.

Note About Services

We do not provide Dental Services or practice dentistry. We contract with Dentists to participate in a Network.

Dentists in the Network are independent of Solstice and are not employees of Solstice. We make payment to Dentists in the Network through various types of agreements. These agreements may include financial incentives to promote dental care in a cost efficient and effective way. Such financial incentives are not meant to affect your access to Necessary Dental Services.

The Dentist-patient relationship is between you and your Dentist. This means the following:

A. You are responsible for choosing your own Dentist.

B. You must decide if any Dentist treating you is right for you. This includes Network Dentists who you choose or Dentists to whom you have been referred.

C. You must decide with your Dentist what care you should receive.

D. Your Dentist is solely responsible for the quality of the care you receive.

We make decisions about eligibility and if a benefit is Covered under the Policy. These decisions are based upon your Policy. We are not liable for any act or omission of a Dentist that has, or is treating you.

Important Information concerning Medicare

Coverage under the Policy is not meant to add to any coverage given by Medicare. In some circumstances, Covered Persons who are enrolled in Medicare may also be enrolled under this Policy. If you are eligible for or enrolled in Medicare, please read the following information carefully.

If you are eligible for Medicare, you must enroll for and maintain coverage under both Medicare Part A and Part B.

If you do not enroll in both, and we are the Secondary Plan as described in Section 8: Coordination of Benefits, we will pay benefits under the Policy as if you were covered under both Medicare Part A and Part B. This means that you may incur a larger out-of-pocket cost for Dental Services.

If you are enrolled in a Medicare Advantage plan, you must follow all rules that require you to seek services from that plan's participating providers. When we are the Secondary Plan, we will pay any benefits available to you under the Policy as if you had followed all rules of the Medicare Advantage plan. If we are the Secondary Plan and you do not follow the rules of the Medicare Advantage plan, you may incur a larger out of pocket cost for Dental Services.

Identification ("ID") Card

You should show your ID Card every time you request Dental Services. Your Dentist may ask for your ID Card to verify Coverage and benefit levels.

Contacting Solstice

Throughout this Certificate, you will find statements that suggest that you contact us for more information.

Whenever you have a question or concern regarding Dental Services or your Policy, or need assistance to resolve a complaint, please contact our Customer Service Department at 1.877.760.2247. Customer Service representatives are available to take your call during regular business hours, Monday through Friday 8am to 6pm EST. At other times, you may leave a message on voicemail. A Customer Service representative will return your call no later than three

(3) business days after receipt of the inquiry.

You may also visit our secure member portal at www.MySolstice.net to obtain claim forms, obtain Plan documents, and review a complete listing of Network Dentists.

To contact Customer Service by mail, please use the following address:

Solstice

P.O. Box 19199

Plantation, Florida 33318

To submit claims, please use the following address:

Solstice

P.O. Box 2057

Farmington Hills, Michigan 48333

Dental Certificate of Coverage Table of Contents

Section 1: Definitions

Section 2: General Provisions

Section 3: Enrollment and Effective Date of Coverage

Section 4: Termination of Coverage

Section 5: COBRA Continuation Coverage Rights

Section 6: Procedures for Obtaining Dental Services

Section 7: Reimbursement

Section 8: Coordination of Benefits

Section 9: Subrogation and Refund of Overpayments

Section 10: Complaint Procedures

Section 11: Covered Dental Services

Section 12: General Exclusions

Attachments:

SCHEDULE OF BENEFITS

NOTICE OF PRIVACY PRACTICES

STATEMENT OF EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 RIGHTS

Section 1: Definitions

This section defines the terms used throughout this Policy. Throughout this Policy, these defined terms may appear with their initial letter capitalized.

Amendment – means any description of additional or alternative provisions that is attached to the Policy.

Amendments are subject to all other terms, conditions, limitations and exclusions of the Policy.

Benefits – means Dental Services provided directly by or through a Dentist.

Congenital Anomaly – means a physical developmental defect that is present at birth and identified within the first twelve (12) months from birth.

Coverage or Covered - means the right to reimbursement for expenses incurred by you for Dental Services covered under the Policy. Coverage is subject to the terms, conditions, limitations and exclusions of the Policy. To be Covered, Dental Services must be provided:

A. When the Policy is in effect;

B. Prior to the date of any individual termination conditions as stated in Section 4:Termination of Coverage;

and

C. When the recipient is a Covered Person.

Copayment - means a fixed amount You pay for a Covered Dental Service or Covered Dental Procedure as shown in the Schedule of Benefits.

Covered Person – means the Subscriber or Enrolled Dependent meeting all eligibility requirements specified in the Policy while Coverage is in effect. References to you and your Dependents throughout this Certificate are references to a Covered Person.

Creditable Coverage - means, with respect to an individual, coverage of the individual under any of the following:

A. A group health plan, as defined in s. 2791 of the Public Health Service Act;

B. Health insurance coverage, consisting of dental care, provided directly, through insurance or reimbursement, or otherwise and including terms and services paid for as dental care, under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance contract offered by a health insurance issuer;

C. Part A or B of Title XVIII of the Social Security Act;

D. Title XIX of the Social Security Act, other than coverage consisting solely of benefits under s. 1928;

E. Chapter 55 of Title 10, United States Code;

F. A medical care program of the Indian Health Service or of a tribal organization;

G. The Florida Comprehensive Health Association, or another state health benefits risk pool;

H. A health plan offered under chapter 89 of Title 5, United States Code;

I. A public health plan as defined by rules adopted by the commission, where, to the greatest extent possible, such rules are consistent with regulations adopted by the United States Department of Health and Human Services; or, J. A health benefit plan under s. 5(e) of the Peace Corps Act (22 U.S.C. 2504(e)).

Dental Service or Dental Procedure – means dental care or treatment recognized by us as a generally accepted form of care or treatment according to prevailing standards of dental practice that is provided by a Dentist to a Covered Person while the Policy is in effect.

Dentist – means any dental practitioner who is duly licensed and qualified under the law of the jurisdiction in which Dental Services are rendered.

Dependent – means the Subscriber's legal spouse, or a dependent child of the Subscriber or a dependent child of the Subscriber's spouse. At the Enrolling Group’s option, references to the spouse of a Subscriber may include a Domestic Partner. All references to the child shall include a natural child, stepchild, adopted child, child Placed for Adoption, or a child for whom legal guardianship has been awarded to the Subscriber or the Subscriber's spouse.

The term “Dependent” does not include anyone enrolled as a Subscriber. A person cannot be a Dependent of more than one Subscriber.

The term "Dependent" will not include any dependent child thirty (30) years of age or older, except as stated in Section 4, sub-section 4.2: Extended Coverage for Handicapped Children. The term “Dependent” includes a child for whom dental care coverage is required through a Qualified Medical Child Support Order or other court or administrative order. The Enrolling Group is responsible for determining if an order meets the criteria of a Qualified Medical Child Support Order. The term “Dependent” does not include a child who is provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan or health benefits plan, or entitled to benefits under Title XVIII of the Social Security Act, Pub.L.74-271 (42 U.S.C. s.1395 et seq.) at the time Dependent Coverage begins or will begin.

The Subscriber agrees to reimburse us for any Dental Services provided to the child at a time when the child did not satisfy these conditions.

Domestic Partner – means a person of the opposite or same sex with whom the Subscriber has established a Domestic Partnership.

Domestic Partnership – means the relationship between the Subscriber and a Domestic Partner. When Domestic Partners are Covered, proof of Domestic Partnership and financial interdependence must be submitted to us in the form of:

A. Registration as a Domestic Partnership, indicating that neither individual has been registered as a member of another Domestic Partnership within the last six (6) months, where such registry exists, or

B. For partners residing where registration does not exist, by an alternative Affidavit of Domestic Partnership, which must be notarized and contain the following information:

1. The partners are both at least eighteen (18) years of age or older and are mentally competent to consent to contract;

2. The partners are not related by blood in a manner that would bar marriage under state law;

3. The partners have been living together on a continuous basis prior to the date of the application;

4. Proof of cohabitation (e.g., a driver’s license, tax return or other sufficient proof); and

5. Proof that the partners are financially interdependent. Two or more of the following are collectively sufficient to establish financial interdependence:

a. A joint bank account;

b. A joint credit card or charge card;

c. Joint obligation on a loan;

d. Status as an authorized signatory on the partner’s bank account, credit card or charge card;

e. Joint ownership of holdings or investments;

f. Joint ownership of residence;

g. Joint ownership of real estate other than residence;

h. Listing of both partners as tenants on the lease of the shared residence;

i. Shared rental payments of residence (need not be shared 50/50);

j. Listing of both partners as tenants on a lease, or shared rental payments, for property other than residence;

k. A common household and shared household expenses, e.g., grocery bills, utility bills, telephone bills, etc. (need not be shared 50/50);

l. Shared household budget for purposes of receiving government benefits;

m. Status of one as representative payee for the other’s government benefits;

n. Joint ownership of major items of personal property (e.g., appliances, furniture);

o. Joint ownership of a motor vehicle;

p. Joint responsibility for child care (e.g., school documents, guardianship);

q. Shared child-care expenses, e.g., babysitting, day care, school bills (need not be shared 50/50);

r. Execution of wills naming each other as executor and/or beneficiary;

s. Designation as beneficiary under the other’s life insurance policy;

t. Designation as beneficiary under the other’s retirement benefits account;

u. Mutual grant of durable power of attorney;

v. Mutual grant of authority to make health care decisions (e.g., health care power of attorney);

w. Affidavit by creditor or other individual able to testify to partners’ financial interdependence; or

x. Other item(s) of proof sufficient to establish economic interdependency under the circumstances of the particular case.

Eligible Person – means a person whose connection with the Enrolling Group meets the eligibility requirements specified in the Policy.

Emergency Condition - means a medical or behavioral condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

A. Placing the health of the person afflicted with such condition (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy;

B. Serious impairment to such person's bodily functions;

C. Serious dysfunction of any bodily organ or part of such person;

D. Serious disfigurement of such person; or

E. A condition described in clause (i), (ii) or (iii) of Section 1867(e)(1)(A) of the Social Security Act.

Emergency Services - means dental screenings, examinations, and evaluations provided to determine if an Emergency Condition exists. If it does, the care, treatment, or surgery reasonably necessary to relieve or eliminate the Emergency Condition which is sought or received within twenty-four (24) hours.

Enrollment Date - means the first day of your Coverage under the Policy or, if earlier, the first day of the Waiting Period that must pass with respect to you before you are eligible to be Covered for benefits.

Enrolled Dependent – means a Dependent who is properly enrolled for Coverage under the Policy.

Enrolling Group – means the employer or other defined or otherwise legally-constituted group to whom the Policy is issued.

Experimental, Investigational or Unproven Services – means, at the time we make a determination regarding Coverage in a particular case, medical, dental, surgical, diagnostic, or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that are:

A. Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use;

B. Not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use;

C. Subject to review and approval by any institutional review board for the proposed use;

D. The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 of the clinical trials as set forth in the FDA regulations (regardless of whether the trial is actually subject to FDA oversight); or

E. Not demonstrated through prevailing peer-reviewed professional literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.

Initial Eligibility Period – means the initial period of time determined by us and the Enrolling Group during which Eligible Persons may enroll under the Policy.

Medicare – means Parts A, B, C, and D of the insurance program established by Title XVIII, United States Social Security Act, as amended.

Member – means the Subscriber or Enrolled Dependent meeting all eligibility requirements specified in the Policy while Coverage is in effect. References to you and your Dependents throughout this Certificate are references to a Covered Person.

Necessary – means Dental Services and supplies which are determined by us through case-by-case assessments of care based on accepted dental practices to be appropriate and are:

A. Required to meet the basic dental needs of the Covered Person;

B. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the Dental Service;

C. Consistent in type, frequency and duration of treatment with scientifically based guidelines of national clinical research, or dental care coverage organizations or governmental agencies that are accepted by us;

D. Consistent with the diagnosis of the condition;

E. Required for reasons other than the convenience of the Covered Person or his or her Dentist; and

F. Demonstrated through prevailing peer-reviewed dental literature to be either:

1. Safe and effective for treating or diagnosing the condition or sickness for which their use is proposed; or

2. Safe with promising efficacy:

a. For treating a life threatening dental disease or condition;

b. In a clinically controlled research setting; and

c. Using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health.

For the purpose of this definition, the term life threatening is used to describe dental diseases or sicknesses or conditions, which are more likely than not to cause death within one (1) year of the date of the request for treatment.

The fact that a Dentist has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular dental disease does not mean that it is a Necessary Covered Dental Service as defined in this Certificate. The definition of Necessary used in this Certificate relates only to Coverage and differs from the way in which a Dentist engaged in the practice of dentistry may define necessary.

Network – means a group of Dentists who are subject to a participation agreement in effect with us, directly or through another entity, to provide Dental Services to you. The participation status of Dentists may change from time to time.

Network Benefits – means Dental Services provided directly by or through a Dentist in the Network.

Network Dentist – means a Dentist who is in the Network.

Open Enrollment Period – means a period of time determined by us and the Enrolling Group during which an Eligible Person may enroll under the Policy after the Initial Eligibility Period.

Orthodontic Lifetime Maximum Benefit – means the maximum amount paid for Covered orthodontic Dental Services during a lifetime under the Policy or any policy issued by us to the Enrolling Group that replaces the Policy.

The Orthodontic Lifetime Maximum Benefit is stated in Section 11.

Out-of-Network Benefits – means the Coverage available for Dental Services provided by a Dentist who is not in the Network.

Out-of-Network Dentist – means a Dentist who is not in the Network.

Placement for Adoption or Placed for Adoption – means the assumption and retention of a legal obligation for total or partial support of a child by a person with whom the child has been placed in that person’s residence in compliance with chapter 63, Florida Statutes, in anticipation of the child’s legal adoption.

Policy or Plan – means the Enrolling Group Contract, the Certificate of Coverage, the application of the Enrolling Group, Schedule of Benefits, Riders and/or Amendments that constitute the agreement regarding the benefits, exclusions and other terms and conditions between us and the Enrolling Group.

Pre-Existing Condition - is a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six (6) month period ending on the Enrollment Date.

Premium – is the periodic fee required for each Covered Person in accordance with the terms of the Policy.

Provider – means any dental practitioner who is duly licensed and qualified under the law of the jurisdiction in which Dental Services are rendered.

Reimbursement Amount – means the amount We will pay for Covered Services as shown in the Schedule of Benefits.

You will be responsible for the Dentist's fee, if any, which is greater than the Reimbursement Amount.

Rider – means any attached description of Dental Services Covered under the Policy. Dental Services provided by a Rider may be subject to payment of additional Premiums. Riders are subject to all other terms, conditions, limitations and exclusions of the Policy.

Subscriber – means an Eligible Person who is properly enrolled for Coverage under the Policy. The Subscriber is the person (who is not a Dependent) on whose behalf the Policy is issued to the Enrolling Group.

Usual and Customary Charge – means the lesser of:

A. The Provider’s normal charge for a similar service or supply; or

B. The Enrolling Group-selected percentile of all charges made by providers of such service or supply in the geographic area where it is received.

Usual and Customary Charges are determined in accordance with our reimbursement policy guidelines. Our reimbursement policy guidelines are developed by us following evaluation and validation of all provider billings in accordance with one or more of the following methodologies:

A. As reported by generally recognized professionals or publications.

B. As utilized for Medicare.

C. As determined by dental staff and outside dental consultants.

The percentile used to determine the Maximum Reimbursable Charge is listed in Section 11. Additional information about the Usual and Customary Charge, including an estimate of the amount we will pay for a particular Out-of- Network Dental Service, is available upon written request.

Waiting Period - means the period that must pass with respect to the individual before the individual is eligible to be Covered for benefits under the terms of this Policy.

Section 2: General Provisions

Section 2.1 Entire Policy

The Policy is issued to the Enrolling Group. The Policy consists of the Enrolling Group Dental Insurance Contract (“Enrolling Group Contract”), Certificate(s), Schedule(s) of Benefits, the Enrolling Group's application, Subscriber enrollment forms, and any Riders and/or Amendments. These documents make up the entire Policy.

Section 2.2 Incontestability

This Policy may not be contested after it has been in force for two (2) years after the Policy Effective Date. This Policy may be contested at any time for nonpayment of Premium or fraudulent misrepresentation.

Section 2.3 Initial Term

This Policy shall begin at 12:01 a.m. local time at the Enrolling Group’s address on the Effective Date set forth on the cover page of the Enrolling Group Contract and shall extend for an initial term of twelve (12) months thereafter (“Initial Term”).

Section 2.4 Renewal Terms

This Policy is renewable at the option of the Enrolling Group at the end of the Initial Term for an additional term of twelve (12) months, and at the end of each twelve (12) month period thereafter (“Renewal Term”). We may modify, change, or amend the Policy, including, but not limited to, changes to Premium rates, for each Renewal Term. We will offer terms of renewal a minimum of forty-five (45) days in advance of the Policy’s Anniversary Date. Any such modifications, changes, or amendments shall be subject to the Enrolling Group’s acceptance. After an authorized officer of the Enrolling Group signs such modifications, changes, or amendments, they shall be made part of the Policy. The renewal Policy shall be accepted and approved without the Enrolling Group’s signature when the Enrolling Group makes payment to us of the first Premium due for the renewal Policy.

For small groups, any modification will be consistent with Florida’s Employee Health Care Access Act and will be effective on a uniform basis among group dental plans with the coverage.

Section 2.5 Payment Terms

The Enrolling Group pays a Premium to us for your participation in the Policy. The amount and term of the Premium is set forth in the Enrolling Group Contract. You may contact your Plan Administrator for information regarding what part of the Premium may be withheld from your salary. You may also get information about the amount that the Enrolling Group is paying on your behalf.

Section 2.6 Grace Period

This Policy has a thirty-one (31) day Grace Period. This means that if a required Premium is not paid on or before the date it is due, it may be paid during the following Grace Period. During the Grace Period, the Policy will stay in force. Full payment must be received by the thirty-first (31st) day of the Grace Period. If full payment is not received by the thirty-first (31st) day of the Grace Period, the Policy will automatically terminate on midnight at the end of the third (3rd) business day after the date that the notice of termination is received by the Enrolling Group, notwithstanding any other provision of the Policy to the contrary.

If the Enrolling Group sends us a notice of termination during the Grace Period, the Enrolling Group must pay Premiums for any period that the Policy was in force. This includes the pro rata share of the Grace Period. If the Policy terminates for the Premium not being paid, all unpaid Premiums are due as well as the Premium due for the Grace Period.

Section 2.7 Reinstatement

The Enrolling Group may apply for reinstatement of the Policy that terminated due to failure to pay the Premium by the end of its Grace Period. The Enrolling Group must request reinstatement from us in writing on the Enrolling Group’s letterhead. The Enrolling Group must pay all past due Premiums, the current month’s Premium, and a reinstatement fee of $25.00 to us. All payments must be submitted within thirty (30) days of the request. If we, in our sole discretion, accept any partial payment of past due Premium, it shall be applied to the most overdue Premium on the account.

If we reinstate the Policy, the coverage provided would resume as of the date the Policy was terminated. We may require the Enrolling Group to authorize automatic electronic fund transfers for payment of Premium. If we do not reinstate the Policy, we will notify the Enrolling Group in writing within forty-five (45) days of our receipt of the request for reinstatement. If we fail to provide timely notice of our decision to not reinstate the Policy, the Policy will be automatically reinstated. We will refund any Premium not earned that was submitted. The refund will be sent with the denial for reinstatement.

Section 2.8 Changes to the Policy

No change will be made to the Policy unless it is made by an Amendment or a Rider that is signed by an officer of Solstice and of the Enrolling Group. No agent has the authority to change the Policy or waive any of its provisions.

Amendments to the Policy are effective after a forty-five (45) day written notice to the Enrolling Group. Riders are effective on the date specified by us. Amendments are subject to all other terms, conditions, limitations and exclusions of the Policy.

Section 2.9 Relationship Between the Parties

The relationships between Solstice and the Dentists in its Network are strictly contractual relationships between independent contractors. The Dentists in the Network are not agents or employees of Solstice. Solstice and our employees are not agents or employees of Dentists in the Network. The relationship between a Dentist in the Network and you is that of Dentist and patient. The Dentist in the Network is solely responsible for the services provided to you.

The relationship between Solstice and the Enrolling Group is strictly a contractual relationship between independent contractors. The Enrolling Group is not an agent or employee of Solstice. Solstice and our employees are not agents or employees of the Enrolling Group.

The relationship between the Enrolling Group and you is that of employer and employee, Dependent or other Coverage classification as explained in the Policy. The Enrolling Group is solely responsible for enrollment and Coverage classification changes. The Enrolling Group is also responsible for the timely payment of the Premiums to us and for notifying you of the termination of the Policy.

Section 2.10 Examination of Covered Persons

In the event of a question or dispute concerning Coverage for Dental Services, we may reasonably require that a Dentist in the Network examine you. The Dentist in the Network shall be acceptable to us. We shall pay for the cost of the examination.

Section 2.11 Clerical Error

If a clerical error or other mistake occurs, that error will not deny your Coverage under the Policy. A clerical error also does not give you the right to benefits.

Section 2.12 Notice

We may provide written notice regarding any aspect of the Policy to an authorized representative of the Enrolling Group. Such written notice shall be deemed notice to all affected Covered Persons. The Enrolling Group is responsible for giving notice to you.

Section 2.13 Worker’s Compensation Not Affected

The Coverage of this Policy does not replace the need for workers compensation insurance.

Section 2.14 Conformity with Statutes

Any provision in this Policy that conflicts with applicable state or federal laws and regulations is hereby amended to conform to the minimum requirements of such state or federal laws and regulations.

Section 2.15 Waiver/Estoppel

Nothing in this Policy is considered to be waived by any party unless the party claiming the waiver receives the waiver in writing. A waiver of one provision does not constitute a waiver of any other. A failure to enforce any provision of the Policy is not a waiver of such provision. A failure to exercise any option provided in the Policy is not a waiver of such option.

Section 2.16 Headings

The headings, titles and any table of contents in the Policy are to guide you through the policy only. The headings, titles and any table of contents shall not affect the meaning or interpretation of the Policy.

Section 2.17 Unenforceable Provisions

Any provision of this Policy that is determined to be illegal or unenforceable by a court of competent jurisdiction, will be modified to agree with the law and the original intent of the Policy to the greatest extent legally permissible;

all other provisions will remain in effect.

Section 2.18 Misrepresentations

In the absence of fraud, all statements made by the Enrolling Group or by a Subscriber will be deemed representations and not warranties. Any statement made for the purpose of effecting insurance shall not avoid such insurance or reduce benefits unless contained in a written instrument that is signed by the Enrolling Group, or the Subscriber, a copy of which has been furnished to the Enrolling Group or Subscriber. No misrepresentation shall avoid this Policy or defeat recovery under the Policy unless such misrepresentation was material. No misrepresentation shall be deemed material unless knowledge by us of the facts misrepresented would have led to a refusal to make such contract.

Section 2.19 Non-English Communications

Our Customer Service Department is able to communicate in multiple languages through a national translation service.

Section 3: Enrollment and Effective Date of Coverage

Section 3.1 Enrollment

Eligible Persons may enroll themselves and their Dependents for Coverage under the Policy during the Initial Eligibility Period or during an Open Enrollment Period. To enroll, an Eligible Person must submit a form provided or approved by us. New Eligible Persons and new Dependents may enroll as described below. If you do not enroll during the Initial Eligibility Period or during an Open Enrollment Period, you must wait twelve (12) months before you can enroll for benefits.

If you enroll for Coverage under the Policy, you must stay enrolled for a period of twelve (12) months. If you disenroll at the end of any twelve (12) month period, you must wait twelve (12) months before you can get coverage again.

If both spouses are Eligible Persons of the Enrolling Group, each may enroll as a Subscriber or be Covered as an eligible Dependent of the other, but not both. If both parents of an eligible Dependent child are enrolled as a Subscriber, only one parent may enroll the child as a Dependent.

Section 3.2 Effective Date of Coverage

There is never Coverage for Dental Services provided before the Effective Date of the Policy.

Coverage is available on the date that the Eligible Person enrolls as long as they enroll during the Eligibility Period.

Section 3.3 Coverage for a Newly Eligible Person

Your Coverage will take effect on the date agreed to by the Enrolling Group and us. Your Coverage will only be effective if we receive the required Premium. Your coverage will only take effect if we receive a properly completed enrollment form. This form must be received within thirty-one (31) days of the date you become eligible.

Section 3.4 Dependent Special Enrollment Period

A Dependent Special Enrollment Period is available during the calendar or plan year for any Dependent who is an Eligible Person but for failure to enroll during a previous Enrollment Period, and whose status is affected by any of the following events:

A. Marriage;

B. Birth;

C. Adoption;

D. Placement for Adoption; or

E. Court-ordered temporary or other custody.

In any of the prior cases, Coverage is effective only if we receive the required notice, Premium, and a completed enrollment form within thirty-one (31) days of the date of the event. For adoption or Placement for Adoption, this time period is extended by an additional thirty (30) days; however if you notify us within the first thirty-one (31) days of the date of the adoption or Placement for Adoption, we will not charge a Premium for those first thirty-one (31) days of Coverage. If you do not comply with these requirements, you will have to wait until the next Open Enrollment Period.

If you timely enroll a Dependent, the Dependent Special Enrollment Period will begin on the later of:

A. The date that dependent coverage is made available; or

B. The date of the marriage, birth, adoption, Placement for Adoption, or custody.

If you enroll a Dependent during the Dependent Special Enrollment Period, Coverage will become effective:

A. In the case of marriage, not later than the first day of the first month beginning after the date the completed request for enrollment is received;

B. In the case of a dependent’s birth, as of the date of such birth;

C. In the case of a dependent’s adoption, or Placement for Adoption, the date of such adoption or Placement for Adoption; and

D. In the case of court-order temporary or other custody, the date of the custody.

Section 3.5 Special Enrollment Period

A Special Enrollment Period is available during the calendar or plan year for an Eligible Person under the following conditions:

A. At the time of the Initial Eligibility Period or Open Enrollment Period, the Eligible Person had existing dental coverage under another “group health plan,” or had “health insurance coverage” as those terms are defined in s. 2791 of the Public Health Service Act; and

B. Such coverage was terminated because of any of the following:

1. Loss of eligibility, including annulment, legal separation, divorce, death, termination of employment, or reduction in hours of employment.

2. Termination of employer contributions.

3. COBRA continuation coverage was exhausted.

If the person had coverage under a prior plan and it was terminated for the following reasons, then a Special Enrollment Period is not available:

A. For cause.

B. For Failure to pay Premiums on a timely basis.

The Policy is only effective if we receive any required Premium and a completed enrollment form within thirty-one

(31) days of the date of coverage under the prior plan terminated.

Section 4: Termination of Coverage

Section 4.1 Conditions for Termination of Coverage

Group-Level Termination

We may terminate or non-renew this Policy upon at least forty-five (45) days prior written notice to the Enrolling Group for one or more of the following reasons:

A. The Enrolling Group has failed to pay Premiums or contributions in accordance with the terms of the Policy, or we have not received timely Premium payments.

B. The Enrolling Group has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the Policy.

C. The Enrolling Group has failed to comply with a material provision of the Plan which relates to rules for employer contributions or group participation.

D. The Enrolling Group has not obeyed the rules relating to employer contribution or group participation rules as the law permits.

E. We cease to offer a particular type of coverage in a market.

F. There is no longer any Covered Person who lives, resides, or works in our service area or in the area in which we are authorized to do business, and, in the case of small groups, we would deny enrollment with respect to such plan under the Employee Health Care Access Act.

If we discontinue dental coverage in a market, then we will provide notice of discontinuation to each affected Enrolling Group and Subscriber at least ninety (90) days prior to the date of discontinuation. We will also offer each affected Enrolling Group the option to purchase all, or in the case of a large group, any other dental insurance coverage currently offered by us in the market.

If we discontinue offering dental coverage in the small or large group markets, then we will provide notice of discontinuation to each affected Enrolling Group and Subscriber at least one hundred eighty (180) days prior to the date of discontinuation.

In exercising the option to discontinue coverage, we will act uniformly without regard to claims experience or any health-status-related factor.

Member-Level Termination

You may lose your status as an Eligible Person, and therefore lose Coverage, based on the following actions by you:

A. Fraud;

B. Material misrepresentation; or

♦ C. Material violation of the terms of the Policy.

We will provide written notice of termination to you forty-five (45) days prior to the termination date. Coverage terminated according to this provision shall be done uniformly, without regard to any health status-related factor.

You may have continuation of Coverage as described in Section 5 or as provided under federal and state laws.

Date of Termination

Your Coverage will automatically terminate on the earliest of the following dates:

♦ A. The date the entire Policy is terminated.

♦ B. The date you cease to be an Eligible Person.

♦ C. The date we receive written notice from either you or the Enrolling Group instructing us to terminate Coverage. Your Coverage may terminate on a later date requested in such a notice.

♦ D. The date you retire or are pensioned under the Enrolling Group's Plan. Your Coverage will not terminate if you continue to meet any applicable eligibility requirements and the Enrolling Group’s Coverage classifications include retirees or pensioners.

Section 4.2 Extended Coverage for Handicapped Dependent Children

Coverage for an Enrolled Dependent who is incapable of self-sustaining employment by reason of mental retardation, or physical handicap will be continued beyond the age listed under the definition of Dependent provided that:

A. The Enrolled Dependent became so incapable prior to the age at which Dependent Coverage would otherwise terminate;

B. The Enrolled Dependent is chiefly dependent upon the Subscriber for support and maintenance;

C. Proof of such incapacity and dependence is furnished to us within thirty-one (31) days of the date the Subscriber receives a request for such proof from us; and

D. Payment of any required Premium for the Enrolled Dependent is continued.

Coverage will continue as long as the Enrolled Dependent is incapacitated and dependent and your Policy remains in effect. Before granting this extension, we may reasonably require that the Enrolled Dependent be examined, at our expense, by a physician designated by us. At reasonable intervals, we may require satisfactory proof of the Enrolled Dependent's incapacity and dependency, including medical examinations at our expense. Such proof will not be required more often than once a year. Failure to provide such satisfactory proof within thirty-one (31) days of the request by us will result in the termination of the Enrolled Dependent's Coverage under the Policy.

Section 4.3 Extended Coverage

A ninety (90) day temporary extension of Coverage will be granted to you on the date of termination if the termination is not voluntary. Coverage will be extended until the earlier of one of the following:

A. Ninety (90) days; or

B. The date you become covered under a succeeding policy providing coverage or services for similar dental procedures.

The temporary extension of Coverage will only apply to the following Dental Services:

A. The Dental Procedures were recommended in writing and commenced by the Dentist while you were Covered under the Policy;

B. The Dental Procedures were procedures for other than routine examinations, prophylaxis, X-rays, sealants, or orthodontic services; and

c. The Dental Procedures were performed within ninety (90) days after your Coverage ceased under the Policy.

All Policy limitations, exclusions, or reductions that would have applied to the specific Dental Procedures had the Coverage not terminated shall apply during the extension of Coverage.

Section 4.4 Payment and Reimbursement Upon Termination

Any reimbursement for Dental Services rendered prior to the effective date of termination will not be affected by the termination of your Coverage. Your request for reimbursement must be furnished as required in Section 7.

Section 5: COBRA Continuation Coverage Rights

Section 5.1 Introduction

Under federal law, a Subscriber and/or his or her Dependents must be given the opportunity to continue health insurance when there is a Qualifying Event that would result in loss of Coverage under the Plan. A Subscriber and/or his or her Dependents may continue the same coverage under which they were covered on the day before the Qualifying Event occurred, unless they move out of that Plan’s coverage area or the Plan is no longer available. A Subscriber and/or his or her Dependents cannot change coverage options until the next Open Enrollment Period.

Continuation of coverage will be available to Enrolling Groups subject to the provisions of COBRA. The Subscriber should contact the Enrolling Group's designated Plan Administrator to see if the Subscriber or any of his or her Dependents are entitled to COBRA continuation of coverage.

Solstice is not the Plan Administrator. Solstice will not provide COBRA continuation of coverage if the Plan Administrator fails to follow the rules under…