Dental Plan
 

Eligibility and Plan Participation 

ELIGIBILITY
You are eligible to participate in the dental plan described in this section of your SPD if you are an active, part-time or full-time employee of the Company who is regularly scheduled to work for at least 20 hours per week. 

You are also eligible to participate in the dental plan if you are a non-employee member of the Board of Directors of Tufts Associated Health Maintenance Organization, Inc. or Tufts Health Plan Foundation during the time that you are a director.

COVERAGE FOR YOUR ELIGIBLE DEPENDENTS
You can provide your eligible dependents with Dental Plan coverage. Your eligible dependents include: 

  • your spouse;
  • your dependent children under age 26;
  • an unmarried dependent child at any age who is incapable of self-support due to a mental or physical handicap; or
  • your domestic partner. 

Definition of “Spouse”: In order to qualify as an eligible dependent, your spouse must be legally married to you in accordance with the state in which you reside.

Definition of “Children”: For plan purposes, your children include your legally adopted children, children placed with you for adoption prior to legal adoption, and each of your stepchildren and foster children who depends on you for support and maintenance. A child placed with you for adoption prior to legal adoption is treated as though the child were a newborn child to you. 

Your children also include any other children:

  • for whom you have legal guardianship;
  • children of a qualified domestic partner;
  • who meet the IRS definition of your dependent; or
  • children for whom the Company is required to provide coverage under a Qualified Medical Child Support Order (QMCSO – see below). 

Handicapped Child: Coverage for a physically or mentally handicapped child may be continued after that child’s nineteenth birthday if you: 

  • notify the Claim Administrator within 72 days of the child’s nineteenth birthday; and
  • complete and return a Disabled Dependent Application. 

You can obtain a Disabled Dependent Application by visiting the forms section of the Delta Dental website at www.deltadentalma.com

Definition of “Domestic Partner”: For plan purposes, a domestic partner is an unmarried employee’s partner of the same or opposite sex who: 

  • is at least 18 years of age;
  • is not married;
  • is not related to the employee by blood (not so closely related by blood as to preclude legal marriage in your state of residence);
  • is the sole domestic partner of the other; and
  • meets the eligibility criteria described below. 

The employee and the Domestic Partner must: 

  • share a mutually exclusive and enduring relationship;
  • have shared a common residence for 12 prior consecutive months and intend to do so indefinitely;
  • be financially interdependent;
  • be jointly responsible for their common welfare; and
  • be committed to a life partnership with each other.

Note: Roommates who do not satisfy the above criteria, parents, and siblings of an employee cannot qualify as Domestic Partners. 

WHEN YOUR COVERAGE BEGINS
If you want to participate in the Dental Plan, you must enroll within 30 days of the date you are hired. If you enroll within 30 days of the date you are hired, coverage for you and your eligible dependents will begin as of your date of hire. 

Actively at Work
You must be actively at work on the date your coverage begins. You are considered to be “actively at work” if you are performing the duties of your job at the Company’s place of business, or at any other place that the Company’s business requires you to go. If you are not actively at work on the date that your participation would otherwise begin, your participation will be postponed until you are actively at work. 

Treatment in Progress
A special rule applies if you or an eligible dependent is undergoing a course of dental treatment which is in progress as of the date that you become covered under the Delta Dental Plan. In this case: 

  • the Delta Dental Plan will be responsible for paying the claim if you had only one visit prior to your becoming covered under the plan; and
  • the previous carrier will be responsible for paying the claim for multiple (two or more) visits prior to your becoming covered under the plan. 
If you do not enroll for Dental Plan coverage within 30 days of the date on which you are first eligible to do so, you will have to wait until the next annual open enrollment period to enroll, unless you have a Change in Status as described below.

COVERAGE LEVELS
You can choose one of the following levels of coverage for your Dental Plan benefits: 

  • Employee only
  • Employee plus one
  • Family 

PAYING FOR YOUR BENEFITS
You and the Company share the cost of your Dental Plan benefits. The cost to you will depend on the plan and level of coverage you select. 

You pay your share of the cost through convenient before-tax payroll deduction contributions. These contributions come out of your pay before federal and (in most cases) state and local taxes are deducted, so they will reduce your taxable income. 

ANNUAL OPEN ENROLLMENT PERIOD
In the fall of each year, the Company sponsors an open enrollment period. During this period, you can elect to enroll for, change, or cancel your Dental Plan coverage. 

If you do not make any changes during the annual open enrollment period, your current level of coverage will automatically continue. 

Any change you make during the annual open enrollment period (for example, adding a new dependent) will go into effect on the next January 1. This election will remain in effect for the next calendar year, unless you have a Change in Status. 

For example, assume that you elect to cancel your Dental Plan coverage during the 2017 annual open enrollment period. This election will go into effect on January 1, 2018, and will remain in effect for the 2018 calendar year. You cannot change this election until the next annual open enrollment period, unless you have a Change in Status. 

CHANGE IN STATUS
In general, you cannot enroll for, change, or cancel your Dental Plan coverage during the year, unless you have a Change in Status. For plan purposes, you are considered to have a Change in Status in the event of: 

  • your marriage or divorce;
  • the death of your spouse, domestic partner, or child;
  • the birth or adoption of a child;
  • the employment or termination of employment of your spouse or domestic partner;
  • switching from part-time to full-time employment of your spouse or domestic partner;
  • you, your spouse, or domestic partner taking an unpaid leave of absence;
  • a significant change in your health coverage that is attributable to your spouse’s or domestic partner’s employment;
  • a dependent loses other health care coverage involuntarily; or
  • a court orders you to cover a child under a Qualified Medical Child Support Order (QMCSO – see below for details). 

Effective Date
Your election to enroll for, change, or cancel your Dental Plan coverage will go into effect as of the date of the change, provided that you make this election within 30 days of the date of the change. 

For example, assume that you have Employee Only coverage, and you get married during the year. In this case, you can choose to cover your new spouse, provided that you make this election within 30 days of your date of marriage. 

If you do not enroll for or make changes to your Dental Plan coverage within 30 days of the date that a Change in Status occurs, you will have to wait until the next annual open enrollment period.

Cancelling Coverage
If you have a Change in Status, you can also elect to cancel your Dental Plan coverage. If you elect to cancel your coverage, you cannot restore it until the next annual open enrollment period, unless you have another Change in Status. 

LAYOFF OR LEAVE OF ABSENCE
You may elect to continue your Dental Plan coverage during a temporary leave of absence for non-FMLA* reasons. If you are in an unpaid status or receiving disability pay, the contributions you would otherwise have paid towards the cost of your coverage will be suspended during the first four months of leave. (Please refer to the repayment options described below.) 

You should contact Human Resources for more information concerning the continuation of your coverage during a layoff or leave of absence. 

Family and Medical (FMLA*) Leave: You may elect to continue your Dental Plan coverage during an authorized Family and Medical (FMLA) leave of absence. If you are in an unpaid status or receiving disability pay, the contributions you would otherwise have paid towards the cost of your coverage will be suspended during the first four months of leave. 

You have two options for repayment: 

  • You can pay your contributions during your leave via check. Checks should be made payable to “Tufts Health Plan” and mailed to: Human Resources, Tufts Health Plan, 705 Mount Auburn Street, Watertown, MA 02472.
  • You can pay your contributions upon your return to work. You will receive an e-mail from Human Resources informing you of the amount you need to repay. You will be given the option to pay this amount either via Payroll (in one pay period or over a few pay periods) or to write a check for the whole amount. 

If you do not return from your leave of absence, you will be responsible for any benefit contributions you have not made during your leave. Tufts Health Plan will deduct the amount you owe from your last check. If you do not receive a last check, a bill will be sent directly to your home and you will be required to pay the entire amount within 14 calendar days. 

You should contact Human Resources for more information concerning the continuation of your benefit coverage during an authorized FMLA leave. 

*Family and Medical Leave Act 

Military Leave: Reservists who are called to active duty with the Armed Forces of the United States have special benefit continuation and reemployment rights under the law (see Administrative Information). In addition, the federal Family and Medical Leave Act (FMLA) was amended to add two new leave rights related to military service, effective January 16, 2009:

  • Active Duty Leave: Eligible employees are entitled to up to 12 weeks of leave because of “any qualifying exigency” due to the fact that the spouse, son, daughter, or parent of the employee is on active duty, or has been notified of an impending call to active duty status, in support of a contingency operation.
  • Injured Service Member Leave: An eligible employee who is the spouse, son, daughter, parent, or next of kin of a covered service member who is recovering from a serious illness or injury sustained in the line of duty on active duty is entitled to up to 26 weeks of leave in a single 12-month period to care for the service member. The employee is entitled to a combined total of 26 weeks for all types of FMLA leave in the single 12-month period.

QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO)

If a Qualified Medical Child Support Order (QMCSO) is issued for your child, that child will be eligible for coverage as required by the order. You should notify Human Resources and elect coverage for the child as soon as reasonably possible following the issuance of a QMCSO. 

A QMCSO is a judgment, decree or order (including approval of a settlement agreement) issued by a court of competent jurisdiction, and satisfies all of the following: 

  • The order specifies your name and last known address, and the child's name and last known address;
  • The order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be determined;
  • The order states the period to which it applies; and
  • The order specifies each plan to which it applies. 

A QMCSO may not require the health insurance policy to provide coverage for any type or form of benefit not otherwise provided under the policy. You can obtain a copy of the rules governing QMCSOs from Human Resources.

WHO INSURES YOUR BENEFITS?
Effective January 1, 2008, your Dental Plan benefits are self-insured by the Company. Dental Plan claims are administered by Delta Dental of Massachusetts (the “Claim Administrator”).