20221223_Veolia to Staff Attachment - Response to No. 110.pdf

VEO-W-22-02 IPUC DR 110 Page 1 of 1
VEOLIA WATER IDAHO, INC. CASE VEO-W-22-02 THIRD PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: Cary REQUEST NO. 110:
Please provide copies of the Health, Vision, and Dental Insurance Plans Veolia provided
to its employees, with cost breakdowns for employee, spouse, and family.

RESPONSE NO. 110:
Please see Attachment 1 through Attachment 5 for the Company’s healthcare plans and
Attachment 6 for cost breakdown for 2023 for employee, employee plus children, employee plus
spouse and family plan coverage level costs.
BENEFIT PLAN
Prepared for
SUEZ Water Resources Inc.
DMO
What Your Plan
Covers and How
Benefits are Paid
Aetna Life Insurance Company
Booklet-certificate
This Booklet-certificate is part of the Group policy between
Aetna Life Insurance Company and the Policyholder

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Booklet-certificate
Managed dental plan
Prepared for:
Policyholder: SUEZ Water Resources Inc.
Policyholder number:GP-0878274-C
Booklet-certificate:1
Group policy effective date: January 1, 2021
Plan name:DMO
Plan effective date: January 1, 2021
Plan issue date:December 6, 2022
Plan revision effective date: January 1, 2023
Underwritten by Aetna Life Insurance Company
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Welcome
Thank you for choosing Aetna.
This is your booklet-certificate. It is one of three documents that together describe the benefits covered by your
Aetna plan for in-network and out-of-network coverage.
This booklet-certificate will tell you about your covered benefits – what they are and how you get them. If you
become covered, this booklet-certificate becomes your certificate of coverage under the group policy, and it
replaces all certificates describing similar coverage that we sent to you before. The second document is the
schedule of benefits. It tells you how we share expenses for eligible dental services and tells you about limits –
like when your plan covers only a certain number of visits.
The third document is the group policy between Aetna Life Insurance Company (“Aetna”) and your
policyholder. Ask your policyholder if you have any questions about the group policy.
Sometimes, we may send you documents that are amendments, endorsements, attachments, inserts or riders.
They change or add to the documents that they’re part of. When you receive these, they are considered part of
your Aetna plan for coverage.
Where to next? Flip through the table of contents or try the Let’s get started! section right after it. The Let's get
started! section gives you a thumbnail sketch of how your plan works. The more you understand, the more you
can get out of your plan.
Welcome to your Aetna plan.
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Table of Contents
Page
Welcome
Let's get started!5
Who the plan covers 8
Medical necessity and referral requirements 11
What are your eligible dental services?12
What rules and limits apply to dental care?14
What your plan doesn't cover - exclusions 17
Who provides the care 20
What the plan pays and what you pay 22
When you disagree - claim decisions and appeals procedures 24
Coordination of benefits (COB)29
When coverage ends 33
Special coverage options after your plan coverage ends 36
General provisions – other things you should know 41
Glossary 44
Discount programs 50
Schedule of benefits Issued with your booklet-certificate
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Let’s get started!
Here are some basics. First things first – some notes on how we use words. Then we explain how your plan
works so you can get the most out of your coverage. But for all the details – and this is very important – you
need to read this entire booklet-certificate and the schedule of benefits. And if you need help or more
information, we tell you how to reach us.
Some notes on how we use words in the booklet-certificate and schedule of benefits
When we say “you” and “your”, we mean you and any covered dependents
When we say “us”, “we”, and “our”, we mean Aetna
Some words appear in bold type and we define them in the Glossary section
Sometimes we use technical dental language that is familiar to dental providers.
What your plan does – providing covered benefits
Your plan provides covered benefits. These are eligible dental services for which your plan has the obligation to
pay.
How your plan works – starting and stopping coverage
Your coverage under the plan has a start and an end. You start coverage after the eligibility and enrollment
process is completed. To learn more see the Who the plan covers section.
You can lose coverage for many reasons. To learn more see the When coverage ends section.
Ending coverage under the plan doesn’t necessarily mean you lose coverage with us. See the Special coverage
options after your plan coverage ends section.
How your plan works while you are covered in-network
Your in-network coverage helps you:
Get and pay for eligible dental services
Pay less when you use in-network providers
Important note:
See the schedule of benefits for any deductibles, copayments, coinsurance, and maximum age or visit limits
that may apply.
Eligible dental services
Eligible dental services meet these requirements:
They are listed in the Eligible dental services section in the schedule of benefits.
They are not carved out in these sections:
–What are your eligible dental services?
–What rules and limits apply to dental care?
–What your plan doesn’t cover – exclusions section. We refer to this section as “Exclusions”.
They are not beyond any limits in the What rules and limits apply to dental care? section and the
schedule of benefits.
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Aetna’s network of dental providers
Aetna’s network of dental providers is there to give you the care you need. You can find in-network providers
and see important information about them most easily on our online provider directory. Log onto our self-
service website.
In-network providers not reasonably available – You can get eligible dental services under your plan that are
provided by an out-of-network provider, if an appropriate in-network provider is not reasonably available. Your
Primary care dentist (PCD) must request access to the out-of-network provider in advance and we must agree.
For more information about the provider directory, PCDs and other in-network providers, see the Who provides
the care section.
Paying for eligible dental services– the general requirements
There are several general requirements for the plan to pay any part of the expense for an eligible dental service.
They are:
The eligible dental service is medically necessary
You get your care from:
-Your PCD
-A specialty dentist after you get a referral from your PCD
You will find details on medical necessity and referral requirements in the Medical necessity and referral
requirements section. You will find the requirement to use an in-network provider and any exceptions in the
Who provides the care section.
Paying for eligible dental services– sharing the expense
Generally, your plan and you will share the expense of your eligible dental services when you meet the general
requirements for paying.
But sometimes your plan will pay the entire expense; and sometimes you will. For more information see the
What the plan pays and what you pay section and see the schedule of benefits.
How your plan works while you are covered out-of-network
The section above told you how your plan works while you are covered in-network. You also have coverage
when you want to get your care from providers who are not part of the Aetna network. It’s called out-of-
network coverage.
Your out-of-network coverage:
Means you can get care from dental providers who are not part of the Aetna network.
Means you may have to pay for services at the time that they are provided. You may be required to pay
the full charges and submit a claim for reimbursement to us. You are responsible for completing and
submitting claim forms for reimbursement of eligible dental services that you paid directly to a dental
provider.
Means you will pay a higher cost share when you use an out-of-network provider.
You will find details on:
Out-of-network providers and any exceptions in the Who provides the care section
Cost sharing in the What the plan pays and what you pay section and your schedule of benefits
Claim information in the When you disagree - claim decisions and appeals procedures section
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How to contact us for help
We are here to answer your questions. You can contact us by registering and logging onto our self-service
website available 24/7 that requires registration and logon at www.aetna.com.
From our website you can get reliable dental information, tools and resources. Online tools will make it easier
for you to:
Make informed decisions about your dental care
View claims
Research care and treatment options
Access information on health and wellness
You can also contact us by:
Calling Aetna at 1-877-238-6200
Writing us at Aetna Life Insurance Company, 151 Farmington Ave, Hartford, CT 06156
Your ID card
You don't need to show an ID card. When visiting a dentist, just provide your:
Name
Date of birth
ID card number or social security number
The dental office can use that information to verify your eligibility and benefits. Your ID number is located on
your digital ID card which you can view or print by going to our self-service website. If you don’t have internet
access, call us. You can also access your ID card when you’re on the go. To learn more, visit us at
www.aetna.com/mobile.
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Who the plan covers
You will find information in this section about:
Who is eligible
When you can join the plan
Who can be on your plan (who can be your dependent)
Adding new dependents
Special times you and your dependents can join the plan
Who is eligible
The policyholder decides and tells us who is eligible for dental care coverage.
When you can join the plan
As an employee you can enroll yourself and your dependents if you live, work or reside in the service area:
At any time
Once each Calendar Year during the annual enrollment period
At other special times during the year (see the Special times you and your dependents can join the plan
section below)
If you do not enroll yourself and your dependents when you first qualify for dental benefits, you may have to
wait until the next annual enrollment period to join.
Who can be on your plan (who can be your dependent)
You can enroll the following family members:
Your legal spouse
Your domestic partner who meets any policyholder rules and requirements under state law
• Your dependent children – yours or your spouse’s or partner’s
-Dependent children must be:
o Under 26 years of age
-Dependent children include:
o Natural children
o Stepchildren
o Adopted children including those placed with you for adoption
o Foster children
o Children you are responsible for under a qualified medical support order or court-order
o Grandchildren in your legal custody
You may continue coverage for a disabled child past the age limit shown above. See the Continuation of
coverage for other reasons in the Special coverage options after your plan coverage ends section for more
information.
Adding new dependents
You can add the following new dependents any time during the year:
A spouse - If you marry, you can put your spouse on your plan.
–We must receive your completed enrollment information not more than 31 days after the date of
your marriage.
–Ask the policyholder when benefits for your spouse will begin. It will be:
o No later than the first day of the first calendar month after the date we receive your completed
enrollment information
o Within 31 days of the date of your marriage.
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A domestic partner - If you enter a domestic partnership, you can enroll your domestic partner on your
dental plan.
–We must receive your completed enrollment information not more than 31 days after the date you
file a Declaration of Domestic Partnership, or not later than 31 days after you provide
documentation required by the policyholder.
–Ask the policyholder when benefits for your domestic partner will begin. It will be either on the date
your Declaration of Domestic Partnership is filed or the first day of the month following the date we
receive your completed enrollment information.
A newborn child – Your newborn child is covered on your dental plan for the first 31 days after birth.
–To keep your newborn covered, we must receive your completed enrollment information within 31
days of birth.
–You must still enroll the child within 31 days of birth even when coverage does not require payment
of an additional premium contribution for the covered dependent.
–If you miss this deadline, your newborn will not have dental benefits after the first 31 days.
An adopted child – A child that you, or that you and your spouse or domestic partner adopts is covered
on your plan for the first 31 days after the adoption is complete.
–To keep your adopted child covered, we must receive your completed enrollment information
within 31 days after the adoption.
–If you miss this deadline, your adopted child will not have dental benefits after the first 31 days.
A stepchild – You may put a child of your spouse or domestic partner on your plan.
–You must complete your enrollment information and send it to us within 31 days after the date of
your marriage or your Declaration of Domestic Partnership with your stepchild’s parent.
–Ask the policyholder when benefits for your stepchild will begin. It is either on the date of your
marriage or the date your Declaration of Domestic Partnership is filed or the first day of the month
following the date we receive your completed enrollment information.
Inform us of any changes
It is important that you inform us of any changes that might affect your benefit status. This will help us
effectively deliver your benefits. Please contact us as soon as possible with changes such as:
Change of address or phone number
Change in marital status
Change of covered dependent status
A covered dependent who enrolls in any other dental plan
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Late entrant rule
The plan does not cover services and supplies given to a person age 5 or more if that person did not enroll in the
plan during one of the following:
The first 31 days the person is eligible for this coverage
Any period of open enrollment agreed to by the policyholder and us
This does not apply to charges incurred for any of the following:
After the person has been covered by the plan for 12 months
As a result of injuries sustained while covered by the plan
Diagnostic and preventive services such as exams, cleanings, fluoride, and images (orthodontia related
services are not included)
Special times you and your dependents can join the plan
You can enroll in these situations:
When you did not enroll in this plan before because:
–You were covered by another group dental plan, and now that other coverage has ended
–You had COBRA, and now that coverage has ended
You have added a dependent because of marriage, birth, adoption, placement for adoption or foster
care. See the Adding new dependents section for more information
When a court orders that you cover a current spouse, domestic partner, or a minor child on your dental
plan.
We must receive your completed enrollment information from you within 31 days of that date on which you no
longer have the other coverage mentioned above.
Effective date of coverage
Your coverage will be in effect as of the date you become eligible for dental benefits.
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Medical necessity and referral requirements
The starting point for covered benefits under your plan is whether the services and supplies are eligible dental
services and medically necessary. See the Eligible dental services and Exclusions sections plus the schedule of
benefits.
This section addresses the medical necessity requirements.
Medically necessary/medical necessity
As we said in the Let's get started! section, medical necessity is a requirement for you to receive a covered
benefit under this plan.
The medical necessity requirements are in the Glossary section, where we define "medically necessary, medical
necessity".
Referrals
You need a referral from your PCD in order to receive coverage for any services a specialty dentist provides. If
you do not have a referral when required, we won’t pay the provider. You will have to pay for services if your
PCD fails to send the referral to us. Refer to the What the plan pays and what you pay section.
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What are your eligible dental services?
The information in this section is the first step to understanding your plan's eligible dental services. If you have
questions about this section, see the How to contact us for help section.
Your plan covers many kinds of dental care services and supplies. But some are not covered at all or are covered
only up to a limit.
You can find out about exceptions and exclusions in the:
Dental provider services benefit below
What rules and limits apply to dental care? section
Exclusions section
Your dental plan
Your dental plan includes in-network and out-of-network providers. This means that it is a network plan. We
explain how this plan works in the Let’s get started section.
Schedule of benefits
Eligible dental services include dental services and supplies provided by dental providers. Your schedule of
benefits includes a detailed list of eligible dental services under your dental plan (including any maximums and
limits that apply to them).
Dental provider services
You can get eligible dental services:
At the dental provider’s office
By way of teledentistry
services for teledentistry are paid based upon the cost share features that apply to
the type of eligible dental service that you get. See your schedule of benefits for details.
The following are not eligible dental services under your plan except as described in the What rules and limits
apply to dental care? section of this booklet-certificate, the schedule of benefits, or a rider or amendment issued
to you for use with this booklet-certificate:
Acupuncture, acupressure and acupuncture therapy
Asynchronous dental treatment
Crown, inlays and onlays, and veneers unless for one of the following:
-It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material
-The tooth is an abutment to a covered partial denture or fixed bridge
Dental implants, false teeth, prosthetic restoration of dental implants, plates, dentures, braces, mouth
guards, and other devices to protect, replace or reposition teeth and removal of implants
Dental services and supplies made with high noble metals (gold or titanium) except as covered in the
schedule of benefits
Dentures, crowns, inlays, onlays, bridges, or other prosthetic appliances or services used for the purpose
of splinting, to alter vertical dimension, to restore occlusion, or correcting attrition, abrasion, or erosion
General anesthesia and intravenous sedation, unless specifically covered and done in connection with
another eligible dental service
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Instruction for diet, tobacco counseling and oral hygiene
Mail order and at-home kits for orthodontic treatment
Orthodontic treatment except as covered in the schedule of benefits
Prefabricated porcelain/ceramic crown – permanent tooth
Services and supplies provided in connection with treatment or care that is not covered under the plan
Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of
appliances that have been damaged due to abuse, misuse or neglect and for an extra set of dentures
Replacement of teeth beyond the normal complement of 32
Services and supplies provided where there is no evidence of pathology, dysfunction or disease, other
than covered preventive services
Space maintainers except when needed to preserve space resulting from the premature loss of
deciduous teeth
Surgical removal of impacted wisdom teeth when removed only for orthodontic reasons
Temporomandibular joint dysfunction/disorder (TMJ)
Dental emergency services
Eligible dental services include dental emergency services provided for a dental emergency. The care provided
must be a covered benefit.
If you have a dental emergency, and are over 50 miles from home, you should consider calling your PCD who
may be more familiar with your dental needs. However, you can get treatment from any dentist including one
that is an out-of-network provider. If you need help in finding a dentist, call us.
If you get treatment from an out-of-network provider for a dental emergency, the plan pays a benefit at the in-
network cost-sharing level of coverage up to the dental emergency services maximum.
For follow-up care to treat the dental emergency, you should use your PCD so that you can get the maximum
level of benefits.
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What rules and limits apply to dental care?
Several rules apply to the dental benefits. Following these rules will help you use your plan to your advantage by
avoiding expenses that are not covered by your plan.
Alternate treatment rule
Sometimes there are several ways to treat a dental problem, all of which provide acceptable results.
If a charge is made for a non-eligible dental service but an eligible dental service would have provided
acceptable results, then your plan will pay a benefit for the eligible dental service.
If a charge is made for an eligible dental service but a different eligible dental service would have provided
acceptable results and is less expensive, then your plan will pay a benefit based upon the least expensive eligible
dental service.
The benefit will be based on the in-network provider’s negotiated charge for the eligible dental service or, in
the case of an out-of-network provider, on the recognized charge.
You should review the differences in the cost of alternate treatment with your dental provider. Of course, you
and your dental provider can still choose the more costly treatment method. You are responsible for any
charges in excess of what your plan will cover.
Coverage for dental work begun before you are covered by the plan
Your plan does not cover dental work that began before you were covered by the plan. This means that the
following dental work is not covered:
An appliance, or modification of an appliance, if an impression for it was made before you were covered
by the plan
A crown, bridge, or cast or processed restoration, if a tooth was prepared for it before you were covered
by the plan
Root canal therapy, if the pulp chamber for it was opened before you were covered by the plan
Orthodontic treatment rule
Orthodontic treatment is covered on the date active orthodontic treatment begins.
The following are not considered orthodontic treatment:
The installation of a space maintainer
A surgical procedure to correct malocclusion
This benefit does not cover charges for the following:
Replacement of broken appliances
Re-treatment of orthodontic cases
Changes in treatment necessitated by an accident
Maxillofacial surgery
Myofunctional therapy
Treatment of cleft palate
Treatment of micrognathia
Treatment of macroglossia
Lingually placed direct bonded appliances and arch wires (i.e. “invisible braces”)
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Comprehensive orthodontic treatment is limited to a:
Lifetime maximum of 24 months of active; usual and customary orthodontic treatment on permanent
dentition; plus an extra 24 months of post-treatment retention.
Lifetime maximum of one full course of active, usual and customary orthodontic treatment, plus post-
treatment retention.
Orthodontic limitation for late enrollees
The plan will not cover the charges for an orthodontic procedure for which an active appliance for that
procedure has been installed within the 2 year period starting with the date you became covered by the plan.
This limit applies only if you do not become enrolled in the plan within 31 days after you first become eligible.
Reimbursement policies
We reserve the right to apply our reimbursement policies to all services including involuntary services. Those
policies may affect the negotiated charge or recognized charge. These policies consider:
The duration and complexity of a service
When multiple procedures are billed at the same time, whether additional overhead is required
Whether an assistant surgeon is necessary for the service
If follow up care is included
Whether other characteristics modify or make a particular service unique
When a charge includes more than one claim line, whether any services described by a claim line are
part of, or incidental to, the primary service provided
The educational level, licensure or length of training of the provider
Aetna reimbursement policies are based on our review of:
Generally accepted standards of dental practice
The views of providers and dentists practicing in the relevant clinical areas
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Replacement rule
Some eligible dental services are subject to your plan’s replacement rule. The replacement rule applies to
replacements of, or additions to existing:
Crowns
Inlays
Onlays
Veneers
Complete dentures
Removable partial dentures
Fixed partial dentures (bridges)
Other prosthetic services
These eligible dental services are covered only when you give us proof that:
While you were covered by the plan:
–You had a tooth (or teeth) extracted after the existing denture, bridge or other prosthetic item
was installed.
–As a result, you need to replace or add teeth to your denture, bridge or other prosthetic item
and:
o The tooth that was removed was not an abutment to a removable or fixed partial
denture, bridge or other prosthetic item installed during the prior 12 months.
o Your present denture is an immediate temporary one that replaces that tooth (or teeth).
A permanent denture is needed and the temporary denture cannot be used as a
permanent denture. Replacement must occur within 12 months from the date that the
temporary denture was installed.
The present item cannot be made serviceable and is:
–A crown installed at least 5 years before its replacement.
–An inlay, onlay, veneer, complete denture, removable partial denture, fixed partial denture
(bridge), or other prosthetic item installed at least 5 years before its replacement.
Tooth missing but not replaced rule
The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges), and
other prosthetic services will be covered if:
The dentures, bridges or other prosthetic items are needed to replace one or more natural teeth that
were removed while you were covered by the plan. (The extraction of a third molar tooth does not
qualify.)
The tooth that was removed was not an abutment to a removable or fixed partial denture, bridge or
prosthetic item installed during the prior 5 years.
Any such appliance, prosthetic item or fixed bridge must include the replacement of an extracted tooth or teeth.
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What your plan doesn’t cover – exclusions
We already told you about the many dental care services and supplies that are eligible for coverage under your
plan in the What are your eligible dental services? section. In that section we also told you that some dental care
services and supplies have exceptions and some are not covered at all (exclusions).
In this section we tell you about exclusions that apply to your plan.
And just a reminder, you'll find benefit and coverage limitations in the schedule of benefits.
Exclusions
The following are not eligible dental services under your plan except as described in:
The What are your eligible dental services? section
The What rules and limits apply to dental care? section
The schedule of benefits
A rider or amendment issued to you for use with this booklet-certificate
Charges for services or supplies
Provided by an out-of-network provider in excess of the recognized charge
Provided for your personal comfort or convenience, or the convenience of any other person, including a
dental provider
Provided in connection with treatment or care that is not covered under the plan
Cancelled or missed appointment charges or charges to complete claim forms
Charges for which you have no legal obligation to pay
Charges that would not be made if you did not have coverage, including:
-Care in charitable institutions
-Care for conditions related to current or previous military service
-Care while in the custody of a governmental authority
Charges in excess of any benefit limits
Any charges in excess of the benefit, dollar, visit, or frequency limits stated in the schedule of
benefits.
Cosmetic services and plastic surgery (except to the extent coverage is specifically provided in the
schedule of benefits)
Cosmetic services and supplies including:
-Plastic surgery
-Reconstructive surgery
-Cosmetic surgery
-Personalization or characterization of dentures or other services and supplies which
improve, alter or enhance appearance
-Augmentation and vestibuloplasty and other services to protect, clean, whiten, bleach or
alter the appearance of teeth; whether or not for psychological or emotional reasons.
Facings on molar crowns and pontics will always be considered cosmetic.
Court-ordered services and supplies
This includes those court ordered services and supplies, or those required as a condition of parole,
probation, release or because of any legal proceeding, unless they are an eligible dental service under
this plan.
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Dental services and supplies
Under any other plan of group benefits provided by the policyholder
Examinations
Any dental examinations needed:
Because a third party requires the exam. Examples include examinations to get or keep a job, or
examinations required under a labor agreement or other contract
To buy insurance or to get or keep a license
To travel
To go to a school, camp, or sporting event, or to join in a sport or other recreational activity
Experimental or investigational
Experimental or investigational drugs, devices, treatments or procedures
Non-medically necessary services
Services, including but not limited to, those treatments, services, prescription drugs and supplies which
are not medically necessary (as determined by Aetna) for the diagnosis and treatment of illness, injury,
restoration of physiological functions, or covered preventive services. This applies even if they are
prescribed, recommended or approved by your physician or dentist.
Other primary payer
Payment for a portion of the charge that another party is responsible for as the primary payer
Outpatient prescription drugs, and preventive care drugs and supplements
Prescribed drugs, pre-medication or analgesia
Personal care, comfort or convenience items
Any service or supply primarily for your convenience and personal comfort or that of a third
party
Providers and other health professionals
Treatment by other than a dentist. However, the plan will cover some services provided by a licensed
dental hygienist under the supervision and guidance of a dentist. These are:
-Scaling of teeth
-Cleaning of teeth
-Topical application of fluoride
Charges submitted for services by an unlicensed provider or not within the scope of the
provider’s license
Services provided by a family member
Services provided by a spouse, civil union partner, domestic partner, parent, child, stepchild,
brother, sister, in-law or any household member.
Services received outside of the United States
Non-dental emergency services received outside of the United States. They are not covered even if they
are covered in the United States under this booklet-certificate.
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Teledentistry
Services given by dental providers that are not contracted with Aetna as teledentistry
providers
Services given when you are not present at the same time as the dental provider
Services including:
-Telephone calls
-Teledentistry kiosks
-Electronic vital signs monitoring or exchanges
Work related illness or injuries
Coverage available to you under workers’ compensation or under a similar program under local, state
or federal law for any illness or injury related to employment or self-employment.
A source of coverage or reimbursement will be considered available to you even if you waived your right
to payment from that source. You may also be covered under a workers’ compensation law or similar
law.
If you submit proof that you are not covered for a particular illness or injury under such law, then that
illness or injury will be considered “not work related” regardless of cause.
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Who provides the care
Just as the starting point for coverage under your plan is whether the services and supplies are eligible dental
services, the foundation for getting covered care is through our network. This section tells you about in-network
providers, out-of-network providers and PCD’s.
In-network providers
We have contracted with dental providers in the service area to provide eligible dental services to you. These
in-network providers make up the network for your plan.
For you to receive the in-network level of benefits you must use in-network providers for eligible dental
services.
The exceptions are:
Dental emergency services – Refer to the What are your eligible dental services? section
In-network providers are not available to provide the eligible dental service that you need
You can find in-network providers and see important information about them by logging onto our self-service
website. You can search our online provider directory, for names and locations of in-network providers.
You will not have to submit claims for treatment received from in-network providers. Your in-network provider
will take care of that for you. And we will directly pay the in-network provider for what the plan owes.
Your PCD
Your primary care dentist (we call that dentist your PCD) will provide you with routine care and get you a
referral to a specialty dentist.
You are required to select a PCD. Each covered family member can select their own PCD. You must select a PCD
for your covered dependent if they are a minor or cannot choose a PCD on their own.
For you to receive the in-network level of benefits, eligible dental services must be accessed through your PCD’s
office. They will provide you with primary care services and initiate referrals for specialty dental care.
How do you choose your PCD?
You choose your PCD from the list of PCDs in our provider directory which is on our self-service website.
What will your PCD do for you?
Your PCD will coordinate your dental care or may provide treatment. They may send you to other in-network
providers.
Your PCD will give you a written or electronic referral to see other in-network providers.
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How do I change my PCD?
You may change your PCD at any time. You can call us or log onto our self-service website to make a change.
The change will become effective as follows:
If we receive the request:The change will become effective on:
th day of the month st day of the next month
th day of the month st day of the month following the next
month
What happens if I do not select a PCD?
Because having a PCD is so important, we may choose one for you. We will notify you of the PCD’s name,
address and telephone number. If you wish, you can change the PCD by following the directions above for How
do I change my PCD?.
Your eligible dental services will be limited to care provided by direct access in-network providers and dental
emergency services.
Out-of-network providers
You also have access to out-of-network providers. This means you can receive eligible dental services from an
out-of-network provider. If you use an out-of-network provider to receive eligible dental services, you are
subject to a higher out-of-pocket expense and are responsible for:
Paying your out-of-network deductible
Your out-of-network coinsurance
Any charges over our recognized charge
Submitting your own claims
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What the plan pays and what you pay
Who pays for your eligible dental services – this plan, both you and this plan or just you? That depends. This
section gives the general rule and explains these key terms:
Your out-of-network deductible
Your coinsurance
Your out-of-network orthodontic treatment maximum
Your dental emergency services maximum
The general rule
When you get eligible dental services:
You pay your out-of-network deductible or office visit copayment
And then
You pay your coinsurance. The schedule of benefits lists the coinsurance that you pay. The coinsurance
amount may vary by the type of expense.
And then
You are responsible for any amounts above the maximum.
Important note – when you pay all
You pay the entire expense for an eligible dental service:
When you get a dental care service or supply that is not medically necessary. See the Medical necessity
and referral requirements section.
When you get an eligible dental service without a referral when your plan requires a referral. See the
Medical necessity and referral requirements section.
In both of these cases, the dental provider may require you to pay the entire charge.
Special financial responsibility
You are responsible for the entire expense of:
Cancelled or missed appointments
Neither you nor we are responsible for:
Charges for which you have no legal obligation to pay
Charges that would not be made if you did not have coverage
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Where your schedule of benefits fits in
This section explains some of the terms you will find in your schedule of benefits.
How your out-of-network deductible works
Your out-of-network deductible is the amount you need to pay for eligible dental services per Calendar Year
before your plan begins to pay for eligible dental services. Your schedule of benefits shows the out-of-network
deductible amount for your plan.
How your coinsurance works
Your coinsurance is the amount you pay for eligible dental services after you have paid your deductible or
office visit copayment. The schedule of benefits shows the coinsurance amount that you will pay for specific
eligible dental services. We are responsible for paying any remaining coinsurance.
How your out-of-network orthodontic treatment maximum works
The out-of-network orthodontic treatment maximum is the most your plan will pay for eligible dental services
per lifetime incurred by you after any applicable deductible and coinsurance. You are responsible for any
amounts above this maximum.
Important note:
See the schedule of benefits for any deductibles, copayments, coinsurance, maximums, maximum age, visit
limits, and other limitations that may apply.
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When you disagree - claim decisions and appeals procedures
In the previous section, we explained how you and we share responsibility for paying for your eligible dental
services.
When a claim comes in, we review it, make a decision and tell you how you and we will split the expense. We
also explain what you can do if you think we got it wrong.
Claim procedures
You or your dental provider are required to send us a claim in writing. You can request a claim form from us. We
will review that claim for payment to the provider or to you as appropriate.
The table below explains the claim procedures as follows:
Notice Requirement Deadline
You should get a claim
form from our self-
service website or call
us
The claim form will
provide instructions
on how to complete
and where to send
the forms
You must send us
notice and proof as
soon as reasonably
possible
If you are unable to
complete a claim
form, you may send
us:
-A description of
services
-Bill of charges
-Any dental
documentation
you received
from your
provider
dental
provider, you will be charged.
The information you receive
for that service is your proof
of loss.
A completed claim
form and any
additional information
required by us
You must send us
notice and proof as
soon as reasonably
possible
Written proof must be
provided for all
benefits
If we challenge any
portion of a claim, the
unchallenged portion
of the claim will be
paid promptly after
the receipt of proof of
loss
Benefits will be paid
as soon as the
necessary proof to
support the claim is
received
If, through no fault of your own, you are not able to meet the deadline for filing a claim, your claim will still be
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accepted if it is filed as soon as possible. Unless you are legally incapacitated, late claims will not be covered if
they are filed more than 27 months after the deadline.
Communicating our claim decisions
The amount of time that we have to tell you about our decision on a claim is shown below.
Post-service claim
A post service claim is a claim that involves dental care services you have already received.
Type of notice Post-service claim
Adverse benefit determinations
We pay many claims at the full rate negotiated charge with an in-network provider and the recognized charge
with an out-of-network provider, except for your share of the costs. But sometimes we pay only some of the
claim. And sometimes we don’t pay at all. Any time we don’t pay even part of the claim, that is called an
“adverse benefit determination” or “adverse decision”.
If we make an adverse benefit determination, we will tell you in writing.
The difference between a complaint and an appeal
A complaint
You may not be happy about a dental provider or an operational issue, and you may want to complain. You can
call or write us. Your complaint should include a description of the issue. You should include copies of any
records or documents that you think are important. We will review the information and provide you with a
written response within 30 calendar days of receiving the complaint. We will let you know if we need more
information to make a decision.
An appeal
You can ask us to review an adverse benefit determination. This is called an appeal. You can appeal by calling us.
Appeals of adverse benefit determinations
You can appeal our adverse benefit determination. We will assign your appeal to someone who was not
involved in making the original decision. You must file an appeal within 180 calendar days from the time you
receive the notice of an adverse benefit determination.
You can appeal by sending a written appeal to the address on the notice of adverse benefit determination or by
calling us. You need to include:
Your name
The policyholder’s name
A copy of the adverse benefit determination
Your reasons for making the appeal
Any other information you would like us to consider
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Another person may submit an appeal for you, including a dental provider. That person is called an authorized
representative. You need to tell us if you choose to have someone else appeal for you (even if it is your dental
provider). You should fill out an authorized representative form telling us that you are allowing someone to
appeal for you. You can get this form on our website or by contacting us. The form will tell you where to send it
to us. You can use an authorized representative at any level of appeal.
You can appeal two times under this plan. If you appeal a second time you must present your appeal within 60
calendar days from the date you receive the notice of the first appeal decision.
Timeframes for deciding appeals
The amount of time that we have to tell you about our decision on an appeal claim depends on the type of
claim. The chart below shows a timetable view of the different types of claims and how much time we have to
tell you about our decision.
Type of notice Post-service
appeal
Exhaustion of appeals process
You must complete the appeal process with us before you can take these actions:
Contact the Connecticut Department of Insurance to request an investigation of a complaint or appeal
File a complaint or appeal with the Connecticut Department of Insurance
Appeal through an external review process
Pursue arbitration, litigation or other type of administrative proceeding
You may contact the Connecticut Department of Insurance for assistance regarding any complaint, grievance or
appeal at the following address:
State of Connecticut Insurance Department
Consumer Affairs Department
P.O. Box 816
Hartford, CT 06142-0816
860-297-3900 or 800-203-3447
[e-mail]
You may also contact the Office of Healthcare Advocate at:
State of Connecticut
Office of the Healthcare Advocate
P.O. Box 1543
Hartford, CT 06144
1-866-297-3992
[e-mail]
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External review
External review is a review done by people in an organization outside of Aetna. This is called an external review
organization (ERO). Sometimes, this is called an independent review organization (IRO).
You have a right to external review only if:
Our claim decision involved medical judgment
We decided the service or supply is not medically necessary or not appropriate
We decided the service or supply is experimental or investigational
You have received an adverse determination
If our claim decision is one for which you can seek external review, we will say that in the notice of adverse
benefit determination or final adverse benefit determination we send you. That notice also will describe the
external review process. It will include a copy of the Request for External Review form at the final adverse
determination level.
You must submit the Request for External Review form:
To the Connecticut Insurance Department
Within 4 months of the date you received the decision from us
And you must include a copy of the notice from us and all other important information that supports
your request
You will need to mail your application for External Review to:
Connecticut Insurance Department
Attention: External Review
P.O. Box 816
Hartford, CT 06142-0816
If you are using an overnight delivery service, mail to:
Connecticut Insurance Department
Attention: External Review
153 Market Street, 7th floor
Hartford, CT 06103
You will pay for any information that you send and want reviewed by the ERO. We will pay for information we
send to the ERO plus the cost of the review.
The Connecticut Insurance Commissioner will forward the appeal to Aetna.
Aetna will contact the ERO that will conduct the review of your claim. The ERO will:
Assign the appeal to one or more independent clinical reviewers that have the proper expertise to do
the review
Consider appropriate credible information that you sent
Follow our contractual documents and your plan of benefits
Send notification of the decision within 45 calendar days of the date we receive your request form and
all the necessary information
We will stand by the decision that the ERO makes, unless we can show conflict of interest, bias or fraud.
How long will it take to get an ERO decision?
We will tell you of the ERO decision not more than 45 calendar days after we receive your Notice of External
Review Form with all the information you need to send in.
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Recordkeeping
We will keep the records of all complaints and appeals for at least 10 years.
Fees and expenses
We do not pay any fees or expenses incurred by you when you submit a complaint or appeal. We will pay for
information we send to the ERO plus the cost of the review.
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Coordination of benefits
Some people have dental coverage under more than one plan. If you do, we will work together with your other
plans to decide how much each plan pays. This is called coordination of benefits (COB).
Key terms
Here are some key terms we use in this section. These terms will help you understand this COB section.
Allowable expense means:
A dental care expense that any of your dental plans cover to any degree. If the dental care service is not
covered by any of the plans, it is not an allowable expense. For example, cosmetic surgery generally is
not an allowable expense under this plan.
In this section we talk about other “plans” which are those plans where you may have other coverage for dental
care expenses, such as:
Group or non-group, blanket, or franchise health insurance policies issued by insurers, HMOs, or health
care service contractors
Labor-management trustee plans, labor organization plans, policyholder organization plans, or
employee benefit organization plans
An automobile insurance policy
Governmental benefits
Any contract that you can obtain or maintain only because of membership in or connection with a
particular organization or group
Here’s how COB works
The primary plan pays first. When this is the primary plan, we will pay your claims first as if the other
plan does not exist.
The secondary plan pays after the primary plan. When this is the secondary plan, we will pay benefits
after the primary plan and will reduce the payment based on any amount the primary plan paid.
We will never pay an amount that, when combined with payments from your other coverage, add up to
more than 100% of the allowable expenses.
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Determining who pays
Reading from top to bottom the first rule that applies will determine which plan is primary and which is
secondary.
A plan that does not contain a COB provision is always the primary plan.
If you are:Primary plan Secondary plan
COB rules for dependent children
Parents who are
married or living
together
of the parent whose
birthday* (month and day
only) falls earlier in the
Calendar Year
*Same birthdays--the plan
that has covered a parent
longer is primary
Parents separated or
divorced or not living
together
With court-order
Parents separated or
divorced or not living
together – court-
order states both
parents are
responsible for
coverage or have joint
custody
Parents separated or
divorced or not living
together and there is
no court-order
The plan of the custodial parent pays first
The plan of the spouse of the custodial parent (if any) pays
second
The plan of the noncustodial parents pays next
The plan of the spouse of the noncustodial parent (if any)
pays last
Child covered by:
Individual who is not a
parent (i.e. stepparent
or grandparent)Child of content above
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Active or inactive employee The plan covering you as an
active employee (or as a
dependent of an active
employee) is primary to a plan
covering you as a laid off or
retired employee (or as a
dependent of a former
employee)
A plan that covers the person
as a laid off or retired
employee (or as a dependent
of a former employee) is
secondary to a plan that
covers the person as an active
employee (or as a dependent
of an active employee)
COBRA or state continuation The plan covering you as an
employee or retiree or the
dependent of an employee or
retiree is primary to COBRA or
state continuation coverage
COBRA or state continuation
coverage is secondary to the
plan that covers the person as
an employee or retiree or the
dependent of an employee or
retiree
Longer or shorter length of
coverage
If none of the above rules determine the order of payment, the
plan that has covered the person longer is primary
Other rules do not apply If none of the above rules apply, the plans share expenses
equally
How are benefits paid?
Primary plan The primary plan pays your claims as if there is no other dental
plan involved.
Secondary plan The secondary plan calculates payment as if the primary plan
did not exist, and then applies that amount to any allowable
expenses under the secondary plan that were not covered by
the primary plan.
The secondary plan will reduce payments so the total
payments do not exceed 100% of the total allowable expense
Benefit reserve
each family member has a
separate benefit reserve for
each Calendar Year
The benefit reserve:
Is made up of the amount that the secondary plan saved
due to COB
Is used to cover any unpaid allowable expenses
Balance is erased at the end of each year
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Other dental coverage updates – contact information
You should contact us if you have any changes to your other coverage. We want to be sure our records are
accurate so your claims are processed correctly.
Right to receive and release needed information
We have the right to release or obtain any information we need for COB purposes. That includes information we
need to recover any payments from your other dental plans.
Right to pay another carrier
Sometimes another plan pays something we would have paid under your plan. When that happens, we will pay
your plan benefit to the other plan.
Right of recovery
If we pay more than we should have under the COB rules, we may recover the excess from:
Any person we paid or for whom we paid
Any other plan that is responsible under these COB rules
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When coverage ends
Coverage can end for a number of reasons. This section tells you how and why coverage ends.
When will your coverage end?
Coverage under this plan will end if:
This plan is no longer available
You voluntarily stop your coverage
The group policy ends
You are no longer eligible for coverage, including when you no longer live, work, or reside in the service
area
Your employment ends
You do not pay any required premium payment
We end your coverage
You become covered under another dental plan offered by your policyholder
Your coverage will end on either the date your employment ends or the day before the first premium
contribution due date that occurs after you stop active work.
When coverage may continue under the plan
Your coverage under this plan will continue if:
illness,
injury, sabbatical or other authorized leave as
agreed to by the policyholder and us.
premium payments are made for you, you
may be able to continue coverage under the
plan as long as the policyholder and we agree
to do so and as described below:
Your coverage may continue, until
stopped by the policyholder, but not
beyond 30 months from the start of
your absence.
premium payments are made for you, you
may be able to continue coverage under the
plan as long as the policyholder and we agree
to do so and as described below:
Your coverage will stop on the date
that your employment ends.
Your job has been eliminated
You have been placed on severance
This plan allows former employees to
continue their coverage.
Special coverage options after your plan
coverage ends section.
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Your employment ends because of a paid or
unpaid medical leave of absence
If premium payments are made for you, you
may be able to continue coverage under the
plan as long as the policyholder and we agree
to do so and as described below:
Your coverage may continue until
stopped by the policyholder but not
beyond 30 months from the start of
the absence.
Your employment ends because of a leave of
absence that is not a medical leave of absence
If premium payments are made for you, you
may be able to continue coverage under the
plan as long as the policyholder and we agree
to do so and as described below:
Your coverage may continue until
stopped by the policyholder but not
beyond 1 month from the start of the
absence.
Your employment ends because of a military
leave of absence.
If premium payments are made for you, you
may be able to continue coverage under the
plan as long as the policyholder and we agree
to do so and as described below:
Your coverage may continue until
stopped by the policyholder but not
beyond 24 months from the start of
the absence.
Notification of when your employment ends
It is the policyholder’s responsibility to let us know when your employment ends. The limits above may be
extended only if we and the policyholder agree in writing to extend them.
When will coverage end for any dependents?
Coverage for your dependent will end if:
Your dependent is no longer eligible for coverage
The group policy ends
You do not make the required premium contribution toward the cost of dependents’ coverage
Your coverage ends for any of the reasons listed above
In addition, coverage for your domestic partner or civil union partner will end on the earlier of:
The date this plan no longer allows coverage for domestic partners or civil unions.
The date the domestic partnership or civil union ends. For domestic partnerships, you should provide
the policyholder a completed and signed Declaration of Termination of Domestic Partnership.
Your dependents coverage will end on the earlier of the date the group policy terminates or as defined by the
policyholder.
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Why would we end your coverage?
We will give you 30 days advance written notice before we end your coverage because you commit fraud or
intentionally misrepresent yourself when you applied for or obtained coverage. You can refer to the General
provisions – other things you should know section for more information on loss of coverage.
On the date your coverage ends, we will refund to the policyholder any prepayments for periods after the date
your coverage ended.
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Special coverage options after your plan coverage ends
This section explains options you may have after your coverage ends under this plan. Your individual situation
will determine what options you will have.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
What are your COBRA rights?
COBRA gives some people the right to keep their dental coverage for 18, 29 or 36 months after a “qualifying
event”. COBRA usually applies to policyholders of group sizes of 20 or more.
Here are the qualifying events that trigger COBRA continuation, who is eligible for continuation and how long
coverage can be continued.
Qualifying event causing
loss of coverage
Covered persons eligible
for continued coverage
Length of continued
coverage
(starts from the day you
lose current coverage)
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When do I receive COBRA information?
The chart below lists who is responsible for giving the notice, the type of notice they are required to give and the
timing.
Policyholder/Group dental plan notification requirements
Notice Requirement Deadline
Aetna
Your active employment
ends for reasons other
than gross misconduct
Your working hours are
reduced
You die
You are a retiree eligible
for retiree dental coverage
and your former
policyholder files for
bankruptcy
Aetna
policyholder or
Aetna
Aetna
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You/your dependents notification requirements
Notice of qualifying event –
qualified beneficiary
Notify the policyholder if:
You divorce or legally
separate and are no
longer responsible for
dependent coverage
Your covered dependent
children no longer qualify
as a dependent under the
plan
Within 60 days of the
qualifying event or
the loss of coverage,
whichever occurs later
Disability notice Notify the policyholder if:
The Social Security
Administration
determines that you or a
covered dependent
qualify for disability status
Within 60 days of the decision
of disability by the Social
Security Administration, and
before the 18 month
coverage period ends
Notice of qualified
beneficiary’s status
change to non-disabled
Notify the policyholder if:
The Social Security
Administration decides
that the beneficiary is no
longer disabled
Within 30 days of the Social
Security Administration’s
decision
Enrollment in COBRA Notify the policyholder if:
You are electing COBRA
60 days from the qualifying
event. You will lose your right
to elect, if you do not:
Respond within the 60
days
And send back your
application
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How can you extend the length of your COBRA coverage?
The chart below shows qualifying events after the start of COBRA (second qualifying events):
Qualifying event Person affected (qualifying
beneficiary)
Total length of continued
coverage
You die
You divorce or legally
separate and are no
longer responsible for
dependent coverage
Your covered dependent
children no longer qualify
as dependent under the
plan
How do you enroll in COBRA?
You enroll by sending in an application and paying the premium. Your policyholder has 30 days to send you a
COBRA election notice. It will tell you how to enroll and how much it will cost. You can take 60 days from the
qualifying event to decide if you want to enroll. You need to send your application and pay the premium. If this
is completed on time, you have enrolled in COBRA.
When is your first premium payment due?
Your first premium payment must be made within 45 days after the date of the COBRA election.
How much will COBRA coverage cost?
For most COBRA qualifying events you and your dependents will pay 102% of the total plan costs. This additional
2% covers administrative fees. If you apply for COBRA because of a disability, the total due will be 150% of the
plan costs.
Can you add a dependent to your COBRA coverage?
You may add a new dependent during a period of COBRA coverage. They can be added for the rest of the COBRA
coverage period if:
They meet the definition of an eligible dependent.
You notified your policyholder within 31 days of their eligibility.
You pay the additional required premiums.
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When does COBRA coverage end?
COBRA coverage ends if:
Coverage has continued for the maximum period.
The plan ends. If the plan is replaced, you may be continued under the new plan.
You and your dependents fail to make the necessary payments on time.
You or a covered dependent become covered under another group dental plan.
You or your dependents are continuing coverage during the 19th to 29th months of a disability, and the
disability ends.
Continuation of coverage for other reasons
What exceptions are there for dental work when coverage ends?
Your dental coverage may end while you or your covered dependent are in the middle of treatment. The plan
does not cover dental services that are given after your coverage terminates. There is an exception. The plan will
cover the following services if they are ordered while you were covered by the plan, and installed within 30 days
after your coverage ends:
Inlays
Onlays
Crowns
Removable bridges
Cast or processed restorations
Dentures
Fixed partial dentures (bridges)
Root canals
Ordered means:
For a denture: The impressions from which the denture will be made were taken
For a root canal: The pulp chamber was opened
For any other item: The teeth which will serve as retainers or supports, or the teeth which are being
restored:
–Must have been fully prepared to receive the item
–Impressions have been taken from which the item will be prepared
How can you extend coverage for your disabled child beyond the plan age limits?
You have the right to extend dental coverage for your dependent child beyond the plan age limits. If your
disabled child:
Is not able to be self-supporting because of mental or physical disability
Depends mainly (more than 50% of income) on you for support
The right to coverage will continue only as long as a physician certifies that your child still is disabled.
We may ask you to send us proof of the disability within 31 days of the date coverage would have ended. Before
we extend coverage, we may ask that your child get a physical exam. We will pay for that exam.
We may ask you to send proof that your child is disabled after coverage is extended. We won’t ask for this proof
more than once a year. You must send it to us within 31 days of our request. If you don’t, we can terminate
coverage for your dependent child.
Your disabled child's coverage will end on the earlier of:
The date the child is no longer disabled and dependent upon you for support
As explained in the When will coverage end for any dependents section
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General provisions – other things you should know
Administrative provisions
How you and we will interpret this booklet-certificate
We prepared this booklet-certificate according to ERISA, and according to other federal and state laws that
apply. You and we will interpret it according to these laws. Also, you are bound by our interpretation of this
booklet-certificate when we administer your coverage, so long as we use reasonable discretion.
How we administer this plan
We apply policies and procedures we’ve developed to administer this plan.
Who’s responsible to you
We are responsible to you for what our employees and other agents do.
We are not responsible for what is done by your providers. They are not our employees or agents.
Coverage and services
Your coverage can change
Your coverage is defined by the group policy. This document may have amendments and riders too. Under
certain circumstances, we or the policyholder or the law may change your plan. When an emergency or
epidemic is declared, we may modify or waive requirements under the plan or your cost share if you are
affected. Only we may waive a requirement of your plan. No other person, including the policyholder or
provider, can do this.
Financial sanctions exclusions
If coverage provided under this booklet-certificate violates or will violate any economic or trade sanctions, the
coverage will be invalid immediately. For example, we cannot pay for eligible dental services if it violates a
financial sanction regulation. This includes sanctions related to a person or a country under sanction by the
United States, unless it is allowed under a written license from the Office of Foreign Assets Control (OFAC). You
can find out more by visiting http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.
Legal action
You must complete the appeal process before you take any legal action against us for any expense or bill. See
the When you disagree - claim decisions and appeals procedures section. You cannot take any action until 60
days after we receive written submission of claim.
No legal action can be brought to recover payment under any benefit after 3 years from the deadline for filing
claims.
Physical examinations and evaluations
At our expense, we have the right to have a provider of our choice examine you. This will be done at all
reasonable times while a claim for benefits is pending or under review.
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Records of expenses
You should keep complete records of your expenses. They may be needed for a claim.
Things that would be important to keep are:
• Names of dental providers, dentists and other providers who provide services
• Dates expenses are incurred
• Copies of all bills and receipts
Honest mistakes and intentional deception
Honest mistakes
You or the policyholder may make an honest mistake when facts are shared with us. When we learn of the
mistake, we may make a fair change in premium contribution or in your coverage. If we do, we will tell you what
the mistake was. We won’t make a change if the mistake happened more than 2 years before we learned of it.
Intentional deception
If we learn that you defrauded us or you intentionally misrepresented material facts, we can take actions that
can have serious consequences for your coverage. These serious consequences include, but are not limited to:
Loss of coverage, starting at some time in the past. If we paid claims for your past coverage, we will
want the money back.
Loss of coverage going forward.
Denial of benefits.
Recovery of amounts we already paid.
We also may report fraud to criminal authorities.
Some other money issues
Assignment of benefits
When you see in-network providers they will bill us directly. If you see out-of-network providers as allowed
under this plan, we may choose to pay you or to pay the providers directly. Unless we have agreed to do so in
writing and to the extent allowed by law, we will not accept an assignment to an out-of-network provider under
this group policy. This may include:
The benefits due
The right to receive payments
Any claim you make for damages resulting from a breach, or alleged breach, of the terms of this group
policy
To request assignment you must complete an assignment form. The assignment form is available from the
policyholder. The completed form must be sent to us for consent.
Recovery of overpayments
We sometimes pay too much for eligible dental services or pay for something that this plan doesn’t cover. If we
do, we can require the person we paid – you or your provider – to return what we paid. If we don’t do that we
have the right to reduce any future benefit payments by the amount we paid by mistake.
Premium contribution
This plan requires the policyholder to make premium contribution payments. If payments are made through a
payroll deduction with the policyholder, the policyholder will forward your payment to us. We will not pay
benefits under this booklet-certificate if premium contributions are not made. Any benefit payment denial is
subject to our appeals procedure. See the When you disagree - claim decisions and appeals procedures section.
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Payment of premiums
The first premium payment for this policy is due on or before your effective date of coverage. Your next
premium payment will be due the 1st of each month (“premium due date”). Each premium payment is to be
paid to us on or before the premium due date.
Your dental information
We will protect your dental information. We will only use or share it with others as needed for your care and
treatment. We will also use and share it to help us process your providers’ claims and manage your plan.
You can get a free copy of our Notice of Privacy Practices. Just call us. When you accept coverage under this
plan, you agree to let your providers share your information with us. We will need information about your
physical and mental condition and care.
Effect of prior plan coverage
If you are in a continuation period from a prior plan at the time you join this plan you may not receive the full
benefit paid under this plan. Your current and prior plan must be offered through the same policyholder.
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Glossary
Aetna
Aetna Life Insurance Company, an affiliate, or a third party vendor under contract with Aetna.
Calendar year
A period of 12 months beginning on January 1st and ending on December 31st.
Coinsurance
Coinsurance is the percentage of the bill that you and this plan have to pay for an eligible dental service. The
schedule of benefits shows the percentage that you have to pay.
Your coinsurance, once you meet any applicable deductibles, for:
PCD services is based on the PCD’s negotiated charge or, if there is no negotiated charge, then on the
PCD’s usual fee
In-network specialty care services is based on the negotiated charge
Out-of-network dentists is based on the recognized charge
Copayments
Copayments are flat fees you pay for certain eligible dental services.
Cosmetic
Services, drugs or supplies that are primarily intended to alter, improve or enhance your appearance.
Covered benefits
Eligible dental services that meet the requirements for coverage under the terms of this plan.
Deductible
The amount you pay for eligible dental services per calendar year before your plan starts to pay.
Dental emergency
Any dental condition that:
Occurs unexpectedly
Requires immediate diagnosis and treatment in order to stabilize the condition
Is characterized by symptoms such as severe pain and bleeding
Dental emergency services
Services and supplies given by a dental provider to treat a dental emergency.
Dental provider
Any individual legally qualified to provide dental services or supplies.
Dentist
A legally qualified dentist licensed to do the dental work he or she performs.
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Directory
The list of in-network providers for your plan. The most up-to-date provider directory for your plan appears on
our self-service website. When searching for an in-network provider, you need to make sure that you are
searching for providers that participate in your specific plan. In-network providers may only be considered in-
network providers for certain Aetna plans.
Effective date of coverage
The date your coverage begins under this booklet-certificate as noted in our records.
Eligible dental services
The benefits, subject to varying cost shares, covered in this plan. These are:
Listed and described in the schedule of benefits.
Not listed as an exception or exclusion in these sections:
–What are your eligible dental services?
–What rules and limits apply to dental care?
–Exclusions.
Not beyond any maximums and limitations in the What rules and limits apply to dental care? section
and schedule of benefits.
Medically necessary. See the Medical necessity and referral requirements section and the Glossary for
more information.
Experimental or investigational
A drug, device, procedure, or treatment that we find is experimental or investigational because:
There is not enough outcome data available from controlled clinical trials published in the peer-reviewed
literature to validate its safety and effectiveness for the illness or injury involved.
The needed approval by the Food and Drug Administration (FDA) has not been given for marketing.
A national medical or dental society or regulatory agency has stated in writing that it is experimental or
investigational or suitable mainly for research purposes.
It is the subject of a Phase I, Phase II or the experimental or research arm of a Phase III clinical trial. These
terms have the meanings given by regulations and other official actions and publications of the FDA and
Department of Health and Human Services.
Written protocols or a written consent form used by a facility provider state that it is experimental or
investigational.
It is provided or performed in a special setting for research purposes.
Group policy
The group policy consists of several documents taken together. These documents are:
The group application
The group policy
The booklet-certificates
The schedules of benefits
Any amendments or riders to the group policy the booklet-certificate, and the schedule of benefits
Health professional
A person who is licensed, certified or otherwise authorized by law to provide medical or dental care services to
the public. For example, providers and dental assistants.
Illness
Poor health resulting from disease of the teeth or gums.
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Injury or injuries
Physical damage done to the teeth or gums.
In-network provider
A provider listed in the directory for your plan.
Lifetime maximum
This is the most this plan will pay for eligible dental services incurred by a covered person during their lifetime.
Medically necessary/medical necessity
Dental care services that we determine a provider using sensible clinical judgment would provide to a patient
for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and
that we determine are:
In accordance with generally accepted standards of dental practice
Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for
the patient’s illness, injury or disease
Not primarily for the convenience of the patient, dentist, or other health care provider
Not more costly than an alternative service or sequence of services at least as likely to produce the same
benefit or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease
Generally accepted standards of dental practice means:
Standards based on credible scientific evidence published in peer-reviewed dental literature and is
Generally recognized by the relevant dental community
Consistent with the standards set forth in policy issues involving clinical judgment
Negotiated charge
This is either:
The amount in-network providers have agreed to accept
The amount we agree to pay directly to in-network providers or third party vendors (including any
administrative fee in the amount paid)
for providing eligible dental services to covered persons in the plan.
Orthodontic treatment
This is any:
Medical service or supply
Dental service or supply
furnished to prevent or to diagnose or to correct a misalignment:
Of the teeth
Of the bite
Of the jaws or jaw joint relationship
whether or not for the purpose of relieving pain.
Out-of-network provider
A provider who is not an in-network provider and does not appear in the directory for your plan, or a
specialty dentist that is seen without a referral.
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Physician
A skilled health professional trained and licensed to practice medicine under the laws of the state
where they practice, specifically, doctors of medicine or osteopathy.
Premium
The amount you or the policyholder are required to pay to Aetna to continue coverage.
Primary care dentist (PCD)
A provider who:
Is selected by a person from the list of PCDs in the directory
Supervises, coordinates and provides initial care and basic dental services to a covered person
Initiates referrals for specialty dental care
Is shown on Aetna's records as your PCD
Provider
A dentist, or other entity or person licensed, or certified under applicable state and federal law to provide
dental care services to you.
Recognized charge
The amount of an out-of-network provider’s charge that is eligible for coverage. You are responsible for
all amounts above what is eligible for coverage. The recognized charge may be less than the provider’s
full charge.
The recognized charge depends on the geographic area where you receive the eligible dental service.
The table below shows the method for calculating the recognized charge for specific services or
supplies:
Service or supply Recognized charge
Important note: If the provider bills less than the amount calculated using the method
above, the recognized charge is what the provider bills.
Recognized charge does not apply to involuntary services.
Special terms used:
Geographic area is normally based on the first three digits of the U.S. Postal Service zip codes.
If we determine we need more data for a particular service or supply, we may base rates on a
wider geographic area such as an entire state.
Involuntary services are eligible dental services that are one of the following:
-Not available from an in-network provider
-Dental emergency services
We will calculate your cost share for involuntary services in the same way as we would if you
received the services from an in-network provider.
Prevailing charge rate is the percentile value reported in a database prepared by FAIR Health,
a nonprofit company. FAIR Health changes these rates periodically. We update our systems
with these changes within 180 days after receiving them from FAIR Health. If the FAIR Health
database becomes unavailable, we have the right to substitute a different database that we
believe is comparable.
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Get the most value out of your benefits:
We have online tools to help you decide the type of care to get and where. Our self-service
website offers tools to help you determine the cost of eligible dental services, compare in-
network providers and schedule office visits with them. See the How to contact us for help
section for the website.
Referral
This only applies to in-network coverage and is a written or electronic authorization made by your PCD to direct
you to an in-network provider for medically necessary services and supplies.
Service area
The geographic area where in-network providers for this plan are located.
Specialty dentist
This is a dental provider who practices in any generally accepted dental or surgical sub-specialty.
Teledentistry
A consultation between you and a dental provider who is performing a clinical dental service.
Services can be provided by:
Two-way audiovisual teleconferencing
Any other method permitted by state law
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Temporomandibular joint dysfunction/disorder (TMJ)
This is:
A TMJ or any similar disorder of the jaw joint
A myofascial pain dysfunction (MPD) of the jaw
Any similar disorder in the relationship between the jaw joint and the related muscles and nerves
Usual fee
This is the fee that a PCD charges its patients in general. Your PCD will give you a copy of the usual fee
schedule if you ask for one. It is not part of this booklet-certificate and may change. It is used only to
calculate your coinsurance amount and is not the basis upon which Aetna pays the PCD. Aetna pays
PCDs based upon separate agreements that may be less than, or unrelated to, the PCD’s usual fee.
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Discount programs
We can offer you discounts on health care related goods or services. Sometimes, other companies provide these
discounted goods and services. These companies are called “third party service providers”. These third party
service providers may pay us so that they can offer you their services.
Third party service providers are independent contractors. The third party service provider is responsible for the
goods or services they deliver. We have the right to change or end the arrangements at any time.
These discount arrangements are not insurance. We don’t pay the third party service providers for the services
they offer. You are responsible for paying for the discounted goods or services.
Wellness and other rewards
You may be eligible to earn rewards for completing certain activities that improve your health, coverage and
experience with us. We may encourage you to access certain dental services or categories of dental providers,
participate in programs, including but not limited to financial wellness programs, utilize tools, improve your
health metrics or continue participation as an Aetna member through incentives. We may provide incentives
based on your participation and outcomes such as:
Modifications to deductible or coinsurance amounts
Merchandise
Coupons
Gift or debit cards
Any combination of the above
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Additional Information Provided by
SUEZ Water Resources Inc.
The following information is provided to you in accordance with the Employee Retirement Income Security Act
of 1974 (ERISA). It is not a part of your booklet-certificate. Your Plan Administrator has determined that this
information together with the information contained in your booklet-certificate is the Summary Plan Description
required by ERISA.
In furnishing this information, Aetna is acting on behalf of your Plan Administrator who remains responsible for
complying with the ERISA reporting rules and regulations on a timely and accurate basis.
Name of Plan:
SUEZ Water Resources Inc. Welfare Plan
Employer Identification Number:
71-0005226
Plan Number:
501
Type of Plan:
Welfare
Type of Administration:
Group Insurance Policy with:
Aetna Life Insurance Company
151 Farmington Avenue
Hartford, CT 06156
Plan Administrator:
SUEZ Water Resources Inc.
461 From Road, Suite 400
Paramus, NJ 07652
Telephone Number: [phone]
Agent For Service of Legal Process:
SUEZ Water Resources Inc.
461 From Road, Suite 400
Paramus, NJ 07652
Service of legal process may also be made upon the Plan Administrator
End of Plan Year:
December 31
Source of Contributions:
Employer and Employee
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Procedure for Amending the Plan:
The Employer may amend the Plan from time to time by a written instrument signed by the person designated
by the Plan Administrator.
ERISA Rights
As a participant in the group insurance plan you are entitled to certain rights and protections under the
Employee Retirement Income Security Act of 1974. 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
and union halls, all documents governing the Plan, including insurance contracts, collective bargaining
agreements, and a copy of the latest annual report (Form 5500 Series) that is filed by the Plan with the U.S.
Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security
Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the
Plan, including insurance contracts, collective bargaining agreements, and copies of the latest annual report
(Form 5500 Series), and an updated Summary Plan Description. The Administrator may make a reasonable
charge for the copies.
Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish
each participant with a copy of this summary annual report.
Receive a copy of the procedures used by the Plan for determining a qualified domestic relations order (QDRO)
or a qualified medical child support order (QMCSO).
Continue Group Health Plan Coverage
Continue health care coverage for yourself, your spouse, or your 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 for the rules governing your COBRA
continuation coverage rights.
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 your interest and that of other plan participants and beneficiaries.
No one, including your employer, your union, 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 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 materials
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 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.
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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 status of a
domestic relations order or a medical child support order, you may file suit in a 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, you should contact:
the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your
telephone directory; or
the Division of Technical Assistance and Inquiries, Employee Benefits Security 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 Employee Benefits Security Administration.
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Confidentiality Notice
Aetna considers personal information to be confidential and has policies and procedures in place to protect it
against unlawful use and disclosure. By "personal information," we mean information that relates to a member's
physical or mental health or condition, the provision of health care to the member, or payment for the provision
of health care or disability or life benefits to the member. Personal information does not include publicly
available information or information that is available or reported in a summarized or aggregate fashion but does
not identify the member.
When necessary or appropriate for your care or treatment, the operation of our health, disability or life
insurance plans, or other related activities, we use personal information internally, share it with our affiliates,
and disclose it to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers), payors
(health care provider organizations, employers who sponsor self-funded health plans or who share responsibility
for the payment of benefits, and others who may be financially responsible for payment for the services or
benefits you receive under your plan), other insurers, third party administrators, vendors, consultants,
government authorities, and their respective agents. These parties are required to keep personal information
confidential as provided by applicable law. In our health plans, participating network providers are also required
to give you access to your medical records within a reasonable amount of time after you make a request.
Some of the ways in which personal information is used include claim payment; utilization review and
management; medical necessity reviews; coordination of care and benefits; preventive health, early detection,
vocational rehabilitation and disease and case management; quality assessment and improvement activities;
auditing and anti-fraud activities; performance measurement and outcomes assessment; health, disability and
life claims analysis and reporting; health services, disability and life research; data and information systems
management; compliance with legal and regulatory requirements; formulary management; litigation
proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators;
underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our
business. We consider these activities key for the operation of our health, disability and life plans. To the extent
permitted by law, we use and disclose personal information as provided above without member consent.
However, we recognize that many members do not want to receive unsolicited marketing materials unrelated to
their health, disability and life benefits. We do not disclose personal information for these marketing purposes
unless the member consents. We also have policies addressing circumstances in which members are unable to
give consent.
To obtain a copy of our Notice of Privacy Practices, which describes in greater detail our practices concerning
use and disclosure of personal information, please call the toll-free Member Services number on your ID card or
visit our Internet site at www.aetna.com.
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Continuation of Coverage During an Approved Leave of Absence Granted to Comply With Federal
Law
This continuation of coverage section applies only for the period of any approved family or medical leave
(approved FMLA leave) required by Family and Medical Leave Act of 1993 (FMLA). If your Employer grants you
an approved FMLA leave for a period in excess of the period required by FMLA, any continuation of coverage
during that excess period will be subject to prior written agreement between Aetna and your Employer.
If your Employer grants you an approved FMLA leave in accordance with FMLA, you may, during the continuance
of such approved FMLA leave, continue Health Expense Benefits for you and your eligible dependents.
At the time you request the leave, you must agree to make any contributions required by your Employer to
continue coverage. Your Employer must continue to make premium payments.
If Health Expense Benefits has reduction rules applicable by reason of age or retirement, Health Expense
Benefits will be subject to such rules while you are on FMLA leave.
Coverage will not be continued beyond the first to occur of:
The date you are required to make any contribution and you fail to do so.
The date your Employer determines your approved FMLA leave is terminated.
The date the coverage involved discontinues as to your eligible class. However, coverage for health expenses
may be available to you under another plan sponsored by your Employer.
Any coverage being continued for a dependent will not be continued beyond the date it would otherwise
terminate.
If Health Expense Benefits terminate because your approved FMLA leave is deemed terminated by your
Employer, you may, on the date of such termination, be eligible for Continuation Under Federal Law on the
same terms as though your employment terminated, other than for gross misconduct, on such date. If the group
contract provides any other continuation of coverage (for example, upon termination of employment, death,
divorce or ceasing to be a defined dependent), you (or your eligible dependents) may be eligible for such
continuation on the date your Employer determines your approved FMLA leave is terminated or the date of the
event for which the continuation is available.
If you acquire a new dependent while your coverage is continued during an approved FMLA leave, the
dependent will be eligible for the continued coverage on the same terms as would be applicable if you were
actively at work, not on an approved FMLA leave.
If you return to work for your Employer following the date your Employer determines the approved FMLA leave
is terminated, your coverage under the group contract will be in force as though you had continued in active
employment rather than going on an approved FMLA leave provided you make request for such coverage within
31 days of the date your Employer determines the approved FMLA leave to be terminated. If you do not make
such request within 31 days, coverage will again be effective under the group contract only if and when Aetna
gives its written consent.
If any coverage being continued terminates because your Employer determines the approved FMLA leave is
terminated, any Conversion Privilege will be available on the same terms as though your employment had
terminated on the date your Employer determines the approved FMLA leave is terminated.
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BENEFIT PLAN
Prepared for
SUEZ Water Resources Inc.
Passive PPO Dental
What Your Plan
Covers and How
Benefits are Paid

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Booklet
Preferred Provider Organization (PPO) dental plan
Prepared for:
Employer:SUEZ Water Resources Inc.
Contract number: ASA-0878274
Booklet:1
Plan name:Passive PPO Dental
Plan effective date: January 1, 2023
Plan issue date:November 3, 2022
Third Party Administrative Services provided by Aetna Life Insurance Company
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Welcome
Thank you for choosing Aetna.
This is your booklet. It is one of two documents that together describe the benefits covered by your Employer’s
self-funded plan for in-network and out-of-network dental coverage.
This booklet will tell you about your covered benefits – what they are and how you get them. It replaces all
booklets describing similar coverage that we sent to you before. The second document is the schedule of
benefits. It tells you how we share expenses for eligible dental services and tells you about limits – like when
your plan covers only a certain number of visits.
Each of these documents may have amendments attached to them. They change or add to the documents
they’re part of.
Where to next? Try the Let’s get started! section. Let's get started! gives you a summary of how your plan works.
The more you understand, the more you can get out of your plan.
Welcome to your Employer’s self-funded plan.
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Table of Contents
Page
Let's get started!..................................................................................................................................1
Who the plan covers............................................................................................................................4
Medical necessity requirements..........................................................................................................7
What are your eligible dental services?...............................................................................................8
What rules and limits apply to dental care?......................................................................................10
What your plan doesn't cover - exclusions........................................................................................13
Who provides the care.......................................................................................................................16
What the plan pays and what you pay ..............................................................................................17
Claim decisions and appeals procedures...........................................................................................19
Coordination of benefits (COB)..........................................................................................................22
When coverage ends .........................................................................................................................25
Special coverage options after your plan coverage ends ..................................................................28
General provisions – other things you should know..........................................................................33
Glossary..............................................................................................................................................36
Discount programs.............................................................................................................................41
Schedule of benefits Issued with your booklet
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1
Let’s get started!
Here are some basics. First things first – some notes on how we use words. Then we explain how your plan
works so you can get the most out of your coverage. But for all the details – and this is very important – you
need to read this entire booklet and the schedule of benefits. And if you need help or more information, we tell
you how to reach us.
Some notes on how we use words in the booklet and schedule of benefits
When we say “you” and “your”, we mean you and any covered dependents
When we say “us”, “we”, and “our”, we mean Aetna when we are describing administrative services
provided by Aetna as Third Party Administrator
Some words appear in bold type and we define them in the Glossary section
Sometimes we use technical dental language that is familiar to dental providers.
What your plan does – providing covered benefits
Your plan provides in-network and out-of-network covered benefits. These are eligible dental services for which
your plan has the obligation to pay.
How your plan works – starting and stopping coverage
Your coverage under the plan has a start and an end. You start coverage after the eligibility and enrollment
process is completed. To learn more see the Who the plan covers section.
You can lose coverage for many reasons. To learn more see the When coverage ends section.
Ending coverage under the plan doesn’t necessarily mean you lose coverage with us. See the Special coverage
options after your plan coverage ends section.
How your plan works while you are covered in-network
Your in-network coverage helps you:
Get and pay for eligible dental services
Pay less when you use in-network providers
See the schedule of benefits for any deductibles, payment percentage, and maximum age or visit
limits that may apply.
Eligible dental services
Eligible dental services meet these requirements:
They are listed in the Eligible dental services section in the schedule of benefits.
They are not carved out in these sections:
–What are your eligible dental services?
–What rules and limits apply to dental care?
–What your plan doesn’t cover – exclusions sections. We refer to this section as “Exclusions”.
They are not beyond any limits in the What rules and limits apply to dental care? section and the
schedule of benefits
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2
Aetna’s network of dental providers
Aetna’s network of dental providers is there to give you the care you need. You can find in-network providers
and see important information about them most easily on our online provider directory. Just log onto our self-
service website. See the How to contact us for help section.
You can choose any dental provider who is in the dental network.
You generally pay less when you get care from in-network providers, so choose in-network providers as soon as
you can. See your schedule of benefits for details.
In-network providers not reasonably available – You can get eligible dental services from an out-of-network
provider at the in-network cost share level when an appropriate in-network provider is not reasonably
available. You must request approval from us before you get the care. Just contact us.
For more information about the provider directory and in-network providers, see the Who provides the care
section.
Paying for eligible dental services– the general requirements
There are general requirements for the plan to pay any part of the expense for an eligible dental service. They
are:
The eligible dental service is medically necessary
You get the eligible dental service from in-network or out-of-network providers
You will find details on medical necessity requirements in the Medical necessity requirements section.
Paying for eligible dental services– sharing the expense
Generally your plan and you will share the expense of your eligible dental services when you meet the general
requirements for paying.
But sometimes your plan will pay the entire expense; and sometimes you will. For more information see the
What the plan pays and what you pay section and see the schedule of benefits.
How your plan works while you are covered out-of-network
The section above told you how your plan works while you are covered in-network. You also have coverage
when you want to get your care from providers who are not part of the Aetna network. It’s called out-of-
network coverage.
Your out-of-network coverage:
Means you can get care from dental providers who are not part of the Aetna network.
Means you may have to pay for services at the time that they are provided. You may be required to pay
the full charges and submit a claim for reimbursement to us. You are responsible for completing and
submitting claim forms for reimbursement of eligible dental services that you paid directly to a dental
provider.
Means the out-of-network cost share applies and you pay more. See the schedule of benefits.
You will find details on:
Out-of-network providers and any exceptions in the Who provides the care section
Cost sharing in the What the plan pays and what you pay section and your schedule of benefits
Claim information in the Claim decisions and appeals procedures section
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3
How to contact us for help
We are here to answer your questions. You can contact us by registering and logging onto our self-service
website available 24/7 that requires registration and logon at www.aetna.com.
In our website you can get reliable dental information, tools and resources. Online tools will make it easier for
you to:
Make informed decisions about your dental care
View claims
Research care and treatment options
Access information on health and wellness
You can also contact us by:
Calling Aetna at 1-877-238-6200
Writing us at Aetna Life Insurance Company, 151 Farmington Ave, Hartford, CT 06156
Your ID card
You don't need to show an ID card. When visiting a dentist, just provide your:
Name
Date of birth
ID card number or social security number
The dental office can use that information to verify your eligibility and benefits. Your ID card number is located
on your digital ID card which you can view or print by going to our self-service website. If you don’t have
internet access, call us. You can also access your ID card when you’re on the go. To learn more, visit us at
www.aetna.com/mobile.
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4
Who the plan covers
You will find information in this section about:
Who is eligible
When you can join the plan
Who can be on your plan (who can be your dependent)
Adding new dependents
Special times you and your dependents can join the plan
Who is eligible
The Employer decides and tells us who is eligible for dental care coverage.
When you can join the plan
As an employee you can enroll yourself and your dependents:
At any time
Once each Calendar Year during the annual enrollment period
At other special times during the year (see the Special times you and your dependents can join the plan
section below)
If you do not enroll yourself and your dependents when you first qualify for dental benefits, you may have to
wait until the next annual enrollment period to join.
Who can be on your plan (who can be your dependent)
You can enroll the following family members on your plan. (They are referred to in this booklet as your
“dependents”.)
Your legal spouse
Your domestic partner who meets any employer rules and requirements under state law
• Your dependent children – yours or your spouse’s or partner’s
-Dependent children must be:
o Under 26 years of age
-Dependent children include:
o Natural children
o Stepchildren
o Adopted children including those placed with you for adoption
o Foster children
o Children you are responsible for under a qualified medical support order or court order
o Grandchildren in your legal custody
You may continue coverage for a disabled child past the age limit shown above. See the Continuation of
coverage for other reasons in the Special coverage options after your plan coverage ends section for more
information.
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5
Adding new dependents
You can add the following new dependents any time during the year:
A spouse - if you marry, you can put your spouse on your plan.
–Your Employer must receive your completed enrollment information not more than 31 days after
the date of your marriage.
–Ask your Employer when benefits for your spouse will begin. It will be:
o No later than the first day of the first calendar month after the date your Employer receives
your completed enrollment information
o Within 31 days of the date of your marriage.
A domestic partner - if you enter a domestic partnership, you can enroll your domestic partner on your
dental plan.
–Your Employer must receive your completed enrollment information not more than 31 days after
the date you file a Declaration of Domestic Partnership, or not later than 31 days after you provide
documentation required by your Employer.
–Ask your Employer when benefits for your domestic partner will begin. It will be either on the date
your Declaration of Domestic Partnership is filed or the first day of the month following the date
your Employer receives your completed enrollment information.
A newborn child – Your newborn child is covered on your dental plan for the first 31 days after birth.
–To keep your newborn covered, your Employer must receive your completed enrollment
information within 31 days of birth.
–You must still enroll the child within 31 days of birth even when coverage does not require payment
of an additional contribution for the covered dependent.
–If you miss this deadline, your newborn will not have dental benefits after the first 31 days.
An adopted child – A child that you, or that you and your spouse or domestic partner adopts is covered
on your plan for the first 31 days after the adoption is complete.
–To keep your adopted child covered, your Employer must receive your completed enrollment
information within 31 days after the adoption.
–If you miss this deadline, your adopted child will not have dental benefits after the first 31 days.
A stepchild – You may put a child of your spouse or domestic partner on your plan.
–You must complete your enrollment information and send it to your Employer within 31 days after
the date of your marriage or your Declaration of Domestic Partnership with your stepchild’s parent.
–Ask your Employer when benefits for your stepchild will begin. It will be either on the date of your
marriage or the date your Declaration of Domestic Partnership is filed or the first day of the month
following the date your Employer receives your completed enrollment information.
Notification of change in status
It is important that you notify your Employer of any changes in your benefit status. This will help your Employer
effectively maintain your benefit status. Please notify your Employer as soon as possible of status changes such
as:
Change of address or phone number
Change in marital status
Change of covered dependent status
A covered dependent who enrolls in any other dental plan
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6
Late entrant rule
Your Employer’s plan does not cover services and supplies given to a person age 5 or older if that person did not
enroll in the Employer’s plan during one of the following:
The first 31 days the person is eligible for this coverage
Any period of open enrollment agreed to by your Employer
This does not apply to charges incurred for any of the following:
After the person has been covered by your Employer’s plan for 12 months
As a result of injuries sustained while covered by your Employer’s plan
Diagnostic and preventive services such as exams, cleanings, fluoride, and images (orthodontia related
services are not included)
Special times you and your dependents can join the plan
You can enroll in these situations:
• When you did not enroll in this plan before because:
-You were covered by another group dental plan, and now that other coverage has ended
-You had COBRA, and now that coverage has ended
• You have added a dependent because of marriage, birth, adoption or foster care. See the Adding new
dependents section for more information
• When a court orders that you cover a current spouse, domestic partner, or a minor child on your dental
plan
Your Employer or the party they designate must receive your completed enrollment information from you
within 31 days of that date on which you no longer have the other coverage mentioned above.
Effective date of coverage
Your coverage will be in effect as of the date you become eligible for dental benefits.
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7
Medical necessity requirements
The starting point for covered benefits under your plan is whether the services and supplies are eligible dental
services and medically necessary. See the Eligible dental services and Exclusions sections plus the schedule of
benefits.
This section addresses the medical necessity requirements.
Medically necessary/medical necessity
As we said in the Let's get started! section, medical necessity is a requirement for you to receive a covered
benefit under this plan.
The medical necessity requirements are in the Glossary section, where we define "medically necessary, medical
necessity”.
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8
What are your eligible dental services?
The information in this section is the first step to understanding your plan's eligible dental services. If you have
questions about this section, see the How to contact us for help section.
Your plan covers many kinds of dental care services and supplies. But some are not covered at all or are covered
only up to a limit.
You can find out about exclusions in the:
Dental provider services benefit below
What rules and limits apply to dental care? section
Exclusions section
Your dental plan
Your dental plan includes in-network and out-of-network providers. This means that it is a network plan. We
explain how this plan works in the Let’s get started section.
Schedule of benefits
Eligible dental services include dental services and supplies provided by a dental provider. Your schedule of
benefits includes a detailed list of eligible dental services under your dental plan (including any maximums and
limits that apply to them).
Dental provider services
You can get eligible dental services:
At the dental provider’s office
By way of teledentistry
services for teledentistry are paid based upon the cost share features that apply to
the type of eligible dental service that you get. See your schedule of benefits for details.
The following are not eligible dental services under your plan except as described in the What rules and limits
apply to dental care? section of this booklet, the schedule of benefits, or a rider or amendment issued to you for
use with this booklet:
Acupuncture, acupressure and acupuncture therapy
Asynchronous dental treatment
Crown, inlays and onlays, and veneers unless for one of the following:
-It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material
-The tooth is an abutment to a covered partial denture or fixed bridge.
Plates, dentures, braces, mouth guards, and other devices to protect, replace or reposition teeth and
removal of implants
Dental services and supplies made with high noble metals (gold or titanium) except as covered in the
schedule of benefits
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9
Dentures, crowns, inlays, onlays, bridges, or other prosthetic appliances or services used for the purpose
of splinting, to alter vertical dimension, to restore occlusion, or correcting attrition, abrasion, or erosion
General anesthesia and intravenous sedation, unless specifically covered and done in connection with
another eligible dental service
Instruction for diet, tobacco counseling and oral hygiene
Orthodontic treatment except as covered in the schedule of benefits
Prefabricated porcelain/ceramic crown – permanent tooth
Services and supplies provided in connection with treatment or care that is not covered under the plan
Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of
appliances that have been damaged due to abuse, misuse or neglect and for an extra set of dentures
Replacement of teeth beyond the normal complement of 32
Services and supplies provided where there is no evidence of pathology, dysfunction or disease, other
than covered preventive services
Space maintainers except when needed to preserve space resulting from the premature loss of
deciduous teeth
Surgical removal of impacted wisdom teeth when removed only for orthodontic reasons
Temporomandibular joint dysfunction/disorder (TMJ)
Dental emergency services
Eligible dental services include dental emergency services provided for a dental emergency. The care provided
must be a covered benefit.
If you have a dental emergency, you should consider calling your in-network provider who may be more
familiar with your dental needs. However, you can get treatment from any dentist including one that is an out-
of-network provider. If you need help in finding a dentist, call us.
If you get treatment from an out-of-network provider for a dental emergency, the plan pays a benefit at the in-
network cost-sharing level of coverage up to the dental emergency services maximum. Any charges above the
dental emergency maximum will be paid at the out-of-network cost-sharing level.
For follow-up care to treat the dental emergency, you should consider using your in-network provider so that
you can get the maximum level of benefits. Follow-up care will be paid at the cost-sharing level that applies to
the type of eligible dental service and the provider that gives you the care.
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10
What rules and limits apply to dental care?
Several rules apply to the dental benefits. Following these rules will help you use your plan to your advantage by
avoiding expenses that are not covered by your plan.
Alternate treatment rule
Sometimes there are several ways to treat a dental problem, all of which provide acceptable results.
If a charge is made for a non-eligible dental service but an eligible dental service would have provided
acceptable results, then your plan will pay a benefit for the eligible dental service.
If a charge is made for an eligible dental service but a different eligible dental service would have provided
acceptable results and is less expensive, then your plan will pay a benefit based upon the least expensive eligible
dental service.
The benefit will be based on the in-network provider’s negotiated charge for the eligible dental service or, in
the case of an out-of-network provider, on the recognized charge.
You should review the differences in the cost of alternate treatment with your dental provider. Of course, you
and your dental provider can still choose the more costly treatment method. You are responsible for any
charges in excess of what your plan will cover.
Coverage for dental work begun before you are covered by the plan
Your plan does not cover dental work that began before you were covered by the plan. This means that the
following dental work is not covered:
An appliance, or modification of an appliance, if an impression for it was made before you were covered
by the plan
A crown, bridge, or cast or processed restoration, if a tooth was prepared for it before you were
covered by the plan
Root canal therapy, if the pulp chamber for it was opened before you were covered by the plan
Orthodontic treatment rule
Orthodontic treatment is covered on the date active orthodontic treatment begins.
The following are not considered orthodontic treatment:
The installation of a space maintainer
A surgical procedure to correct malocclusion
This benefit does not cover charges for the following:
Replacement of broken appliances
Re-treatment of orthodontic cases
Changes in treatment necessitated by an accident
Maxillofacial surgery
Myofunctional therapy
Treatment of cleft palate
Treatment of micrognathia
Treatment of macroglossia
Lingually placed direct bonded appliances and arch wires (i.e. “invisible braces”)
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11
Orthodontic limitation for late enrollees
The plan will not cover the charges for an orthodontic procedure for which an active appliance for that
procedure has been installed within the 2 year period starting with the date you became covered by the plan.
This limit applies only if you do not become enrolled in the plan within 31 days after you first become eligible.
Reimbursement policies
We reserve the right to apply our reimbursement policies to all services including involuntary services. Those
policies may affect the negotiated charge or recognized charge. These policies consider:
The duration and complexity of a service.
When multiple procedures are billed at the same time, whether additional overhead is required
Whether an assistant surgeon is necessary for the service
If follow up care is included
Whether other characteristics modify or make a particular service unique
When a charge includes more than one claim line, whether any services described by a claim line are
part of, or incidental to, the primary service provided
The educational level, licensure or length of training of the provider
Our reimbursement policies are based on our review of:
Generally accepted standards of dental practice
The views of providers and dentists practicing in the relevant clinical areas
Replacement rule
Some eligible dental services are subject to your plan’s replacement rule. The replacement rule applies to
replacements of, or additions to existing:
Inlays
Onlays
Implants
Veneers
Complete dentures
Removable partial dentures
Fixed partial dentures (bridges)
Other prosthetic services
These eligible dental services are covered only when you give us proof that:
While you were covered by the plan:
–You had a tooth (or teeth) extracted after the existing denture, bridge or other prosthetic item was
installed.
–As a result, you need to replace or add teeth to your denture, bridge or other prosthetic item and:
o The tooth that was removed was not an abutment to a removable or fixed partial
denture, bridge or other prosthetic item installed during the prior 5 years.
o Your present denture is an immediate temporary one that replaces that tooth (or teeth).
A permanent denture is needed and the temporary denture cannot be used as a
permanent denture. Replacement must occur within 12 months from the date that the
temporary denture was installed.
The present item cannot be made serviceable, and is:
–A crown installed at least 5 years before its replacement.
–An inlay, onlay, veneer, complete denture, removable partial denture, fixed partial denture (bridge),
implant, or other prosthetic item installed at least 5 years before its replacement.
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Tooth missing but not replaced rule
The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges), and
other prosthetic services will be covered if:
The dentures, bridges or other prosthetic items are needed to replace one or more natural teeth that
were removed while you were covered by the plan. (The extraction of a third molar tooth does not
qualify.)
The tooth that was removed was not an abutment to a removable or fixed partial denture, bridge or
prosthetic item installed during the prior 5 years.
Any such appliance, prosthetic item or fixed bridge must include the replacement of an extracted tooth or teeth.
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What your plan doesn’t cover –exclusions
We already told you about the many dental care services and supplies that are eligible for coverage under your
plan in the What are your eligible dental services? section. In that section we also told you that some dental care
services and supplies have exclusions and some are not covered at all (exclusions).
In this section we tell you about the exclusions that apply to your plan.
And just a reminder, you'll find benefit and coverage limitations in the schedule of benefits.
Exclusions
The following are not eligible dental services under your plan except as described in:
What are your eligible dental services? section
What rules and limits apply to dental care? section
The schedule of benefits
A rider or amendment issued to you for use with this booklet
Charges for services or supplies
Provided by an out-of-network provider in excess of the recognized charge
Provided for your personal comfort or convenience, or the convenience of any other person, including a
dental provider
Provided in connection with treatment or care that is not covered under the plan
Cancelled or missed appointment charges or charges to complete claim forms
Charges for which you have no legal obligation to pay
Charges that would not be made if you did not have coverage, including:
-Care in charitable institutions
-Care for conditions related to current or previous military service
-Care while in the custody of a governmental authority
Charges in excess of any benefit limits
Any charges in excess of the benefit, dollar, visit, or frequency limits stated in the schedule of benefits.
Cosmetic services and plastic surgery (except to the extent coverage is specifically provided in the
schedule of benefits)
Cosmetic services and supplies including:
-Plastic surgery
-Reconstructive surgery
-Cosmetic surgery
-Personalization or characterization of dentures or other services and supplies which improve, alter
or enhance appearance
-Augmentation and vestibuloplasty and other services to protect, clean, whiten, bleach, alter the
appearance of teeth whether or not for psychological or emotional reasons
Facings on molar crowns and pontics will always be considered cosmetic
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Court-ordered services and supplies
This includes those court ordered services and supplies, or those required as a condition of parole,
probation, release or because of any legal proceeding, unless they are an eligible dental service under
this plan.
Dental services and supplies
Those covered under any other plan of group benefits provided by the Customer
Examinations
Any dental examinations needed:
Because a third party requires the exam. Examples include examinations to get or keep a job, or
examinations required under a labor agreement or other contract.
To buy insurance or to get or keep a license.
To travel.
To go to a school, camp, or sporting event, or to join in a sport or other recreational activity.
Experimental or investigational
Experimental or investigational drugs, devices, treatments or procedures
Non-medically necessary services
Services, including but not limited to, those treatments, services, prescription drugs and supplies which are not
medically necessary (as determined by Aetna) for the diagnosis and treatment of illness, injury, restoration of
physiological functions, or covered preventive services. This applies even if they are prescribed, recommended
or approved by your physician or dentist.
Other primary payer
Payment for a portion of the charge that another party is responsible for as the primary payer
Outpatient prescription drugs, and preventive care drugs and supplements
Prescribed drugs, pre-medication or analgesia
Personal care, comfort or convenience items
Any service or supply primarily for your convenience and personal comfort or that of a third
party
Providers and other health professionals
Treatment by other than a dentist. However, the plan will cover some services provided by a licensed
dental hygienist under the supervision and guidance of a dentist. These are:
-Scaling of teeth
-Cleaning of teeth
-Topical application of fluoride.
Charges submitted for services by an unlicensed provider or not within the scope of the
provider’s license.
Services provided by a family member
Services provided by a spouse, civil union partner, domestic partner, parent, child, stepchild,
brother, sister, in-law or any household member
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Services received outside of the United States
Non-dental emergency services received outside of the United States. They are not covered
even if they are covered in the United States under this booklet.
Teledentistry
Services given by dental providers that are not contracted with Aetna as teledentistry providers
Services given when you are not present at the same time as the dental provider
Services including:
-Telephone calls
-Teledentistry kiosks
-Electronic vital signs monitoring or exchanges
Work related illness or injuries
Coverage available to you under workers’ compensation or under a similar program under local, state
or federal law for any illness or injury related to employment or self-employment.
A source of coverage or reimbursement will be considered available to you even if you waived your right
to payment from that source. You may also be covered under a workers’ compensation law or similar
law.
If you submit proof that you are not covered for a particular illness or injury under such law, then that
illness or injury will be considered “not work related” regardless of cause.
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Who provides the care
Just as the starting point for coverage under your plan is whether the services and supplies are eligible dental
services, the foundation for getting covered care is through our network. This section tells you about in-network
and out-of-network providers.
In-network providers
We have contracted with dental providers to provide eligible dental services to you. These dental providers
make up the network for your plan.
For you to pay less under this plan you should use in-network providers for eligible dental services.
You don’t have to use in-network providers:
For dental emergency services – Refer to the What are your eligible dental services? section.
When they are not available to provide eligible dental services that you need. See the Let’s get started
section for more information.
You can find in-network providers and see important information about them by logging onto our self-service
website. You can search our online provider directory for names and locations of in-network providers.
You will not have to submit claims for treatment received from in-network providers. Your in-network provider
will take care of that for you. And we will directly pay the in-network provider for what the plan owes.
Out-of-network providers
You also have access to out-of-network providers. This means you can receive eligible dental services from an
out-of-network provider. If you use an out-of-network provider to receive eligible dental services, you are
subject to a higher out-of-pocket expense and are responsible for:
Paying your out-of-network deductible
Your out-of-network payment percentage
Any charges over our recognized charge
Submitting your own claims
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What the plan pays and what you pay
Who pays for your eligible dental services – this plan, both you and this plan or just you? That depends. This
section gives the general rule and explains these key terms:
Your deductible
Your payment percentage
Your maximums
Your dental emergency services maximum
We also remind you that sometimes you will be responsible for paying the entire bill – for example, if you get
care that is not an eligible dental service.
The general rule
When you get eligible dental services:
You pay your deductible
And then
The schedule of benefits lists how much you pay and your plan pays. The payment percentage may vary
by the type of expense.
And then
You are responsible for any amounts above the Calendar Year and lifetime maximums.
When we say “expense” in this general rule, we mean the negotiated charge for in-network providers and
recognized charge for out-of-network providers. See the Glossary section for what these terms mean.
Important note – when you pay all
You pay the entire expense for an eligible dental service when you get a dental care service or supply that is not
medically necessary. See the Medical necessity requirements section.
The dental provider may require you to pay the entire charge. And any amount you pay will not count towards
your deductible or towards your Calendar Year and lifetime maximums.
Special financial responsibility
You are responsible for the entire expense of:
Cancelled or missed appointments
Neither you nor we are responsible for:
Charges for which you have no legal obligation to pay
Charges that would not be made if you did not have coverage
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Where your schedule of benefits fits in
This section explains some of the terms you will find in your schedule of benefits.
How your deductible works
Your deductible is the amount you need to pay for eligible dental services per Calendar Year before your plan
begins to pay for eligible dental services. Your schedule of benefits shows the deductible amounts for your plan.
How we count your deductible
When you see in-network providers, we count the negotiated charge toward your in-network deductible.
When you see out-of-network providers, we count the recognized charge toward your out-of-network
deductible.
How your payment percentage works
Your payment percentage is the amount you pay for eligible dental services after you have paid your
deductible. The schedule of benefits shows the payment percentage this plan will pay for specific eligible dental
services. You are responsible for paying any remaining payment percentage.
How your maximum works
The maximum is the most your plan will pay for eligible dental services per Calendar Year and lifetime incurred
by you or your covered dependent after any applicable deductible and payment percentage. You are
responsible for any amounts above the maximum.
Important note:
See the schedule of benefits for any deductibles, payment percentage, maximum and maximum age, visit limits,
and other limitations that may apply.
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Claim decisions and appeals procedures
In the previous section, we explained how you and the plan share responsibility for paying for your eligible
dental services.
When a claim comes in, your employer decides how you and the plan will split the expense. We also explain
what you can do if you think we got it wrong.
Claims are processed in the order in which they are received.
Claim procedures
You or your dental provider are required to send us a claim in writing. You can request a claim form from us. We
will review that claim for payment to the provider or to you as appropriate.
The table below explains the claim procedures as follows:
Notice Requirement Deadline
You should get a claim
form from our self-
service website or call
us
The claim form will
provide instructions on
how to complete and
where to send the
forms
You must send us
notice and proof as
soon as reasonably
possible
If you are unable to
complete a claim form,
you may send us:
-A description of
services
-Bill of charges
-Any dental
documentation
you received
from your
dental provider
dental
provider, you will be charged.
The information you receive
for that service is your proof
of loss.
A completed claim
form and any
additional information
required by your
employer
You must send us notice
and proof as soon as
reasonably possible
Written proof must be
provided for all
benefits
If we challenge any
portion of a claim, the
unchallenged portion
of the claim will be
paid promptly after
the receipt of proof of
loss
Benefits will be paid as
soon as the necessary
proof to support the claim
is received
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If, through no fault of your own, you are not able to meet the deadline for filing a claim, your claim will still be
accepted if it is filed as soon as possible. Unless you are legally incapacitated, late claims will not be covered if
they are filed more than 27 months after the deadline.
Communicating our claim decisions
The amount of time that we have to tell you about our decision on a claim is shown below.
Post-service claim
A post service claim is a claim that involves dental care services you have already received.
Type of notice Post-service claim
Adverse benefit determinations
We pay many claims at the full rate negotiated charge with in-network providers and the recognized charge
with out-of-network providers, except for your share of the costs. But sometimes we pay only some of the
claim. And sometimes we don’t pay at all. Any time we don’t pay even part of the claim, that is called an
“adverse benefit determination” or “adverse decision”.
If we make an adverse benefit determination, we will tell you in writing.
The difference between a complaint and an appeal
A complaint
You may not be happy about a dental provider or an operational issue, and you may want to complain. You can
call or write us. Your complaint should include a description of the issue. You should include copies of any
records or documents that you think are important. We will review the information and provide you with a
written response within 30 calendar days of receiving the complaint. We will let you know if we need more
information to make a decision.
An appeal
You can ask us to review an adverse benefit determination. This is called an appeal. You can appeal by calling us.
Appeals of adverse benefit determinations
You can appeal our adverse benefit determination. We will assign your appeal to someone who was not
involved in making the original decision. You must file an appeal within 180 calendar days from the time you
receive the notice of an adverse benefit determination.
You can appeal by sending a written appeal to the address on the notice of adverse benefit determination or by
calling us. You need to include:
Your name
The employer’s name
A copy of the adverse benefit determination
Your reasons for making the appeal
Any other information you would like us to consider
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Another person may submit an appeal for you, including a dental provider. That person is called an authorized
representative. You need to tell us if you choose to have someone else appeal for you (even if it is your dental
provider). You should fill out an authorized representative form telling us that you are allowing someone to
appeal for you. You can get this form on our website or by contacting us. The form will tell you where to send it
to us. You can use an authorized representative at any level of appeal.
You can appeal two times under this plan. If you appeal a second time you must present your appeal within 60
calendar days from the date you receive the notice of the first appeal decision.
Timeframes for deciding appeals
The amount of time that we have to tell you about our decision on an appeal claim depends on the type of
claim. The chart below shows a timetable view of the different types of claims and how much time we have to
tell you about our decision.
Type of notice Post-service appeal
Exhaustion of appeals process
You must complete the appeal process with us before you can take these actions:
Pursue arbitration, litigation or other type of administrative proceeding
Recordkeeping
We will keep the records of all complaints and appeals for at least 10 years.
Fees and expenses
We do not pay any fees or expenses incurred by you when you submit a complaint or appeal.
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Coordination of benefits
Some people have dental coverage under more than one plan. If you do, we will work together with your other
plans to decide how much each plan pays. This is called coordination of benefits (COB).
Key terms
Here are some key terms we use in this section. These terms will help you understand this COB section.
Allowable expense means:
A dental care expense that any of your dental plans cover to any degree. If the dental care service is not
covered by any of the plans, it is not an allowable expense. For example, cosmetic surgery generally is
not an allowable expense under this plan.
In this section we talk about other “plans” which are those plans where you may have other coverage for dental
care expenses, such as:
Group or non-group, blanket, or franchise health insurance policies issued by insurers, HMOs, or health
care service contractors
Labor-management trustee plans, labor organization plans, employer organization plans, or employee
benefit organization plans
An automobile insurance policy
Governmental benefits
Any contract that you can obtain or maintain only because of membership in or connection with a
particular organization or group
Here’s how COB works
The primary plan pays first. When this is the primary plan, we will pay your claims first as if the other
plan does not exist.
The secondary plan pays after the primary plan. When this is the secondary plan, we will pay benefits
after the primary plan and will reduce the payment based on any amount the primary plan paid.
We will never pay an amount that, when combined with payments from your other coverage, add up to
more than 100% of the allowable expenses.
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Determining who pays
Reading from top to bottom the first rule that applies will determine which plan is primary and which is
secondary.
A plan that does not contain a COB provision is always the primary plan.
If you are:Primary plan Secondary plan
COB rules for dependent children
Parents who are married
or living together of the parent whose
birthday* (month and day
only) falls earlier in the
Calendar Year
*Same birthdays--the plan
that has covered a parent
longer is primary
Parents separated or
divorced or not living
together
With court-order
Parents separated or
divorced or not living
together – court-order
states both parents are
responsible for coverage
or have joint custody
Parents separated or
divorced or not living
together and there is no
court-order
The plan of the custodial parent pays first
The plan of the spouse of the custodial parent (if any) pays
second
The plan of the noncustodial parents pays next
The plan of the spouse of the noncustodial parent (if any)
pays last
Child covered by:
Individual who is not a
parent (i.e. stepparent or
grandparent)Child of content above
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Active or inactive employee The plan covering you as an
active employee (or as a
dependent of an active
employee) is primary to a plan
covering you as a laid off or
retired employee (or as a
dependent of a former
employee)
A plan that covers the person
as a laid off or retired
employee (or as a dependent
of a former employee) is
secondary to a plan that
covers the person as an active
employee (or as a dependent
of an active employee)
COBRA or state continuation The plan covering you as an
employee or retiree or the
dependent of an employee or
retiree is primary to COBRA or
state continuation coverage
COBRA or state continuation
coverage is secondary to the
plan that covers the person as
an employee or retiree or the
dependent of an employee or
retiree
Longer or shorter length of
coverage
If none of the above rules determine the order of payment, the
plan that has covered the person longer is primary
Other rules do not apply If none of the above rules apply, the plans share expenses
equally
How are benefits paid?
Primary plan The primary plan pays your claims as if there is no other dental
plan involved
Secondary plan The secondary plan calculates payment as if the primary plan
did not exist, and then applies that amount to any allowable
expenses under the secondary plan that were not covered by
the primary plan.
The secondary plan will reduce payments so the total
payments do not exceed 100% of the total allowable expense
Other dental coverage updates – contact information
You should contact us if you have any changes to your other coverage. We want to be sure our records are
accurate so your claims are processed correctly.
Right to receive and release needed information
We have the right to release or obtain any information we need for COB purposes. That includes information we
need to recover any payments from your other dental plans.
Right to pay another carrier
Sometimes another plan pays something we would have paid under your plan. When that happens, we will pay
your plan benefit to the other plan.
Right of recovery
If we pay more than we should have under the COB rules, we may recover the excess from:
Any person we paid or for whom we paid
Any other plan that is responsible under these COB rules
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When coverage ends
Coverage can end for a number of reasons. This section tells you how and why coverage ends.
When will your coverage end?
Coverage under this plan will end if:
This plan is no longer available
You voluntarily stop your coverage
The group contract ends
You are no longer eligible for coverage
Your employment ends
You do not pay any required fee payment
We end your coverage
You become covered under another dental plan offered by your employer
Your coverage will end on either the date your employment ends or the day before the first fee contribution due
date that occurs after you stop active work.
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When coverage may continue under the plan
Your coverage under this plan will continue if:
illness,
injury, sabbatical or other authorized leave as
agreed to by your employer and us.
Your coverage may continue, until
stopped by your employer, but not
beyond 30 months from the start of
your absence.
Your coverage will stop on the date
that your employment ends.
Your job has been eliminated
You have been placed on severance
This plan allows former employees to
continue their coverage
Special coverage options after your plan
coverage ends section.
Your coverage may continue until
stopped by your employer but not
beyond 30 months from the start of
the absence.
Your coverage may continue until
stopped by your employer but not
beyond 1 month from the start of the
absence.
Your coverage may continue until
stopped by your employer but not
beyond 24 months from the start of
the absence.
It is your employer’s responsibility to let us know when your employment ends. The limits above may be
extended only if your employer agrees in writing to extend them.
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When will coverage end for any dependents?
Coverage for your dependent will end if:
Your dependent is no longer eligible for coverage
The group contract ends
You do not make the required fee contribution toward the cost of dependents’ coverage
Your coverage ends for any of the reasons listed above
In addition, coverage for your domestic partner or civil union partner will end on the earlier of:
The date this plan no longer allows coverage for domestic partners or civil unions
The date the domestic partnership or civil union ends. For domestic partnerships, you should provide
the customer a completed and signed Declaration of Termination of Domestic Partnership.
Your dependents coverage will end on the earlier of the date the group contract terminates or as defined by the
employer.
What happens to your dependents if you die?
Coverage for dependents may continue for some time after your death. See the Special coverage options after
your plan coverage ends section for more information.
Why would we end your coverage?
We will give you 30 days advance written notice before we end your coverage because you commit fraud or
intentionally misrepresent yourself when you applied for or obtained coverage. You can refer to the General
provisions – other things you should know section for more information on loss of coverage.
On the date your coverage ends, we will refund to the employer any prepayments for periods after the date
your coverage ended.
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Special coverage options after your plan coverage ends
This section explains options you may have after your coverage ends under this plan. Your individual situation
will determine what options you will have.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
What are your COBRA rights?
COBRA gives some people the right to keep their dental coverage for 18, 29 or 36 months after a “qualifying
event”. COBRA usually applies to employer of group sizes of 20 or more.
Here are the qualifying events that trigger COBRA continuation, who is eligible for continuation and how long
coverage can be continued.
Qualifying event causing loss
of coverage
Covered persons eligible for
continued coverage
Length of continued coverage
(starts from the day you lose
current coverage)
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When do I receive COBRA information?
The chart below lists who is responsible for giving the notice, the type of notice they are required to give and the
timing.
Employer/Group dental plan notification requirements
Notice Requirement Deadline
employer or
Aetna
Your active
employment ends for
reasons other than
gross misconduct
Your working hours are
reduced
You die
You are a retiree
eligible for retiree
dental coverage and
your former employer
files for bankruptcy
employer or
Aetna
Aetna
–
employer or Aetna
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You/your dependents notification requirements
Notice of qualifying event –
qualified beneficiary
Notify the employer if:
You divorce or legally
separate and are no
longer responsible for
dependent coverage
Your covered
dependent children no
longer qualify as a
dependent under the
plan
Within 60 days of the
qualifying event or
the loss of coverage,
whichever occurs later
Disability notice Notify the employer if:
The Social Security
Administration
determines that you or
a covered dependent
qualify for disability
status
Within 60 days of the decision
of disability by the Social
Security Administration, and
before the 18 month
coverage period ends
Notice of qualified
beneficiary’s status
change to non-disabled
Notify the employer if:
The Social Security
Administration decides
that the beneficiary is
no longer disabled
Within 30 days of the Social
Security Administration’s
decision
Enrollment in COBRA Notify the employer if:
You are electing
COBRA
60 days from the qualifying
event. You will lose your right
to elect, if you do not:
Respond within the 60
days
And send back your
application
How can you extend the length of your COBRA coverage?
The chart below shows qualifying events after the start of COBRA (second qualifying events):
Qualifying event Person affected (qualifying
beneficiary)
Total length of continued
coverage
You die
You divorce or legally
separate and are no
longer responsible for
dependent coverage
Your covered
dependent children
no longer qualify as
dependent under the
plan
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How do you enroll in COBRA?
You enroll by sending in an application and paying the fee. Your employer has 30 days to send you a COBRA
election notice. It will tell you how to enroll and how much it will cost. You can take 60 days from the qualifying
event to decide if you want to enroll. You need to send your application and pay the fee. If this is completed on
time, you have enrolled in COBRA.
When is your first fee due?
Your first fee payment must be made within 45 days after the date of the COBRA election.
How much will COBRA coverage cost?
For most COBRA qualifying events you and your dependents will pay 102% of the total plan costs. This additional
2% covers administrative fees. If you apply for COBRA because of a disability, the total due will be 150% of the
plan costs.
Can you add a dependent to your COBRA coverage?
You may add a new dependent during a period of COBRA coverage. They can be added for the rest of the COBRA
coverage period if:
They meet the definition of an eligible dependent
You notified your employer within 31 days of their eligibility
You pay the additional required fees
When does COBRA coverage end?
COBRA coverage ends if:
Coverage has continued for the maximum period
The plan ends. If the plan is replaced, you may be continued under the new plan
You and your dependents fail to make the necessary payments on time
You or a covered dependent become covered under another group dental plan
You or your dependents are continuing coverage during the 19th to 29th months of a disability, and the
disability ends
Continuation of coverage for other reasons
What exceptions are there for dental work when coverage ends?
Your dental coverage may end while you or your covered dependent are in the middle of treatment. The plan
does not cover dental services that are given after your coverage terminates. There is an exception. The plan will
cover the following services if they are ordered while you were covered by the plan, and installed within 30 days
after your coverage ends:
Inlays
Onlays
Crowns
Removable bridges
Cast or processed restorations
Dentures
Fixed partial dentures (bridges)
Root canals
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Ordered means:
For a denture: The impressions from which the denture will be made were taken
For a root canal: The pulp chamber was opened
For any other item: The teeth which will serve as retainers or supports, or the teeth which are being
restored:
- Must have been fully prepared to receive the item
- Impressions have been taken from which the item will be prepared
How can you extend coverage for your disabled child beyond the plan age limits?
You have the right to extend dental coverage for your dependent child beyond the plan age limits. If your
disabled child:
Is not able to be self-supporting because of mental or physical disability
Depends mainly (more than 50% of income) on you for support
The right to coverage will continue only as long as a physician certifies that your child still is disabled.
We may ask you to send us proof of the disability within 31 days of the date coverage would have ended. Before
we extend coverage, we may ask that your child get a physical exam. We will pay for that exam.
We may ask you to send proof that your child is disabled after coverage is extended. We won’t ask for this proof
more than once a year. You must send it to us within 31 days of our request. If you don’t, we can terminate
coverage for your dependent child.
Your disabled child's coverage will end on the earlier of:
The date the child is no longer disabled and dependent upon you for support
As explained in the When will coverage end for any dependents section
How can you extend coverage for a child in college on medical leave?
You have the right to extend coverage for your dependent college student who takes a medically necessary
leave of absence from school. The right to coverage will be extended until the earlier of:
One year after the leave of absence begins
The date coverage would otherwise end
To extend coverage the leave of absence must:
Begin while the dependent child is suffering from a serious illness or injury
Cause the dependent child to lose status as a full-time student under the plan
Be certified by the treating physician as medically necessary due to a serious illness or injury
We must receive documentation or certification of the medical necessity for a leave of absence either:
At least 30 days prior to the absence, if the medical reason for the absence and the absence are
foreseeable
30 days after the start date of the medical leave of absence from school
The physician treating your child will be asked to keep us informed of any changes.
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General provisions – other things you should know
Administrative provisions
How you and we will interpret this booklet
We prepared this booklet according to ERISA, and according to other federal and state laws that apply. You and
we will interpret it according to these laws. Also, you are bound by our interpretation of this booklet when we
administer your coverage, so long as we use reasonable discretion.
How we administer this plan
We apply policies and procedures we’ve developed to administer this plan.
Who’s responsible to you
We are responsible to you for what our employees and other agents do.
We are not responsible for what is done by your providers. They are not our employees or agents.
Coverage and services
Your coverage can change
Your coverage is defined by the group contract. This document may have amendments too. Under certain
circumstances, we or the customer or the law may change your plan. When an emergency or epidemic is
declared, we may modify or waive requirements under the plan or your cost share if you are affected. Only we
may waive a requirement of your plan. No other person, including the customer or provider, can do this.
Financial sanctions exclusions
If coverage provided under this booklet violates or will violate any economic or trade sanctions, the coverage
will be invalid immediately. For example, we cannot pay for eligible dental services if it violates a financial
sanction regulation. This includes sanctions related to a person or a country under sanction by the United States,
unless it is allowed under a written license from the Office of Foreign Assets Control (OFAC). You can find out
more by visiting http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.
Legal action
You must complete the appeal process before you take any legal action against us for any expense or bill. See
the When you disagree - claim decisions and appeals procedures section. You cannot take any action until 60
days after we receive written submission of claim
No legal action can be brought to recover payment under any benefit after 3 years from the deadline for filing
claims.
Physical examinations and evaluations
At our expense, we have the right to have a provider of our choice examine you. This will be done at all
reasonable times while a claim for benefits is pending or under review.
Records of expenses
You should keep complete records of your expenses. They may be needed for a claim.
Things that would be important to keep are:
Names of dental providers, dentists and other providers who provide services
Dates expenses are incurred
Copies of all bills and receipts
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Honest mistakes and intentional deception
Honest mistakes
You or the employer may make an honest mistake when facts are shared with us. When we learn of the mistake,
we may make a fair change in fee contribution or in your coverage. If we do, we will tell you what the mistake
was. We won’t make a change if the mistake happened more than 2 years before we learned of it.
Intentional deception
If we learn that you defrauded us or you intentionally misrepresented material facts, we can take actions that
can have serious consequences for your coverage. These serious consequences include, but are not limited to:
Loss of coverage, starting at some time in the past. If we paid claims for your past coverage, we will
want the money back.
Loss of coverage going forward.
Denial of benefits.
Recovery of amounts we already paid.
We also may report fraud to criminal authorities.
Some other money issues
Assignment of benefits
When you see in-network providers they will usually bill us directly. When you see out-of-network providers,
we may choose to pay you or to pay the providers directly. Unless we have agreed to do so in writing and to the
extent allowed by law, we will not accept an assignment to an out-of-network provider under this group
contract. This may include:
The benefits due
The right to receive payments
Any claim you make for damages resulting from a breach, or alleged breach, of the terms of this group
contract
To request assignment you must complete an assignment form. The assignment form is available from the
customer. The completed form must be sent to us for consent.
Recovery of overpayments
We sometimes pay too much for eligible dental services or pay for something that this plan doesn’t cover. If we
do, we can require the person we paid – you or your provider – to return what we paid. If we don’t do that we
have the right to reduce any future benefit payments by the amount we paid by mistake.
Payment of fees
The first fee payment for this contract is due on or before your effective date of coverage. Your next fee
payment will be due the 1st of each month (“fee due date”). Each fee payment is to be paid to us on or before
the fee due date.
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Your dental information
We will protect your dental information. We will only use or share it with others as needed for your care and
treatment. We will also use and share it to help us process your providers’ claims and manage your plan.
You can get a free copy of our Notice of Privacy Practices. Just call us. When you accept coverage under this
plan, you agree to let your providers share your information with us. We will need information about your
physical and mental condition and care.
Effect of prior plan coverage
If you are in a continuation period from a prior plan at the time you join this plan you may not receive the full
benefit paid under this plan. Your current and prior plan must be offered through the same customer.
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Glossary
Aetna
Aetna Life Insurance Company, an affiliate, or a third party vendor under contract with Aetna.
Calendar year
A period of 12 months beginning on January 1st and ending on December 31st.
Calendar year maximum
This is the most this plan will pay for eligible dental services incurred by you during the Calendar Year.
Contribution
The amount you or the customer are required to pay to Aetna to continue coverage.
Cosmetic
Services, drugs or supplies that are primarily intended to alter, improve or enhance your appearance.
Covered benefits
Eligible dental services that meet the requirements for coverage under the terms of this plan.
Deductible
The amount you pay for eligible dental services per Calendar Year before your plan starts to pay.
Dental emergency
Any dental condition that:
Occurs unexpectedly
Requires immediate diagnosis and treatment in order to stabilize the condition
Is characterized by symptoms such as severe pain and bleeding
Dental emergency services
Services and supplies given by a dental provider to treat a dental emergency.
Dental emergency services maximum
The most the plan will pay for eligible dental services incurred by any one covered person for any one dental
emergency is called the dental emergency services maximum.
Dental provider
Any individual legally qualified to provide dental services or supplies.
Dentist
A legally qualified dentist licensed to do the dental work he or she performs.
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Directory
The list of in-network providers for your plan. The most up-to-date provider directory for your plan appears on
our self-service website. When searching for in-network providers, you need to make sure that you are
searching for providers that participate in your specific plan. In-network providers may only be considered in-
network providers for certain Aetna plans.
Effective date of coverage
The date your coverage begins under this booklet as noted in our records.
Eligible dental services
The benefits, subject to varying cost shares, covered in this plan. These are:
Listed and described in the schedule of benefits.
Not listed as an exception or exclusion in these sections:
–What are your eligible dental services?
–What rules and limits apply to dental care?
–Exclusions.
Not beyond any maximums and limitations in the What rules and limits apply to dental care?
section and the schedule of benefits.
Medically necessary. See the Medical necessity requirements section and the Glossary for more
information.
Experimental or investigational
A drug, device, procedure, or treatment that we find is experimental or investigational because:
There is not enough outcome data available from controlled clinical trials published in the peer-reviewed
literature to validate its safety and effectiveness for the illness or injury involved.
The needed approval by the Food and Drug Administration (FDA) has not been given for marketing.
A national medical or dental society or regulatory agency has stated in writing that it is experimental or
investigational or suitable mainly for research purposes.
It is the subject of a Phase I, Phase II or the experimental or research arm of a Phase III clinical trial. These
terms have the meanings given by regulations and other official actions and publications of the FDA and
Department of Health and Human Services.
Written protocols or a written consent form used by a facility provider state that it is experimental or
investigational.
It is provided or performed in a special setting for research purposes.
Group contract
The group contract consists of several documents taken together. These documents are:
The group application
The group contract
The booklet
The schedules of benefits
Any amendments to the group contract the booklet, and the schedule of benefits
Health professional
A person who is licensed, certified or otherwise authorized by law to provide medical or dental care services to
the public. For example, providers and dental assistants.
Illness
Poor health resulting from disease of the teeth or gums.
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Injury or injuries
Physical damage done to the teeth or gums.
In-network provider
A provider listed in the directory for your plan.
Lifetime maximum
This is the most this plan will pay for eligible dental services incurred by a covered person during their lifetime.
Medically necessary/medical necessity
Dental care services that we determine a provider using sensible clinical judgment would provide to a patient
for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and
that we determine are:
In accordance with generally accepted standards of dental practice
Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for
the patient’s illness, injury or disease
Not primarily for the convenience of the patient, dentist, or other health care provider
Not more costly than an alternative service or sequence of services at least as likely to produce the same
benefit or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease
Generally accepted standards of dental practice means standards based on credible scientific evidence
published in peer-reviewed dental literature and is:
Generally recognized by the relevant dental community
Consistent with the standards set forth in policy issues involving clinical judgment
Negotiated charge
This is either:
The amount in-network providers have agreed to accept
The amount we agree to pay directly to in-network providers or third party vendors (including
any administrative fee in the amount paid)
for providing eligible dental services to covered persons in the plan.
Orthodontic treatment
This is any:
Medical service or supply
Dental service or supply
furnished to prevent or to diagnose or to correct a misalignment:
Of the teeth
Of the bite
Of the jaws or jaw joint relationship
whether or not for the purpose of relieving pain.
Orthodontic treatment lifetime maximum
The most the plan will pay for eligible dental services for orthodontic treatment that you incur during your
lifetime is called the orthodontic treatment lifetime maximum.
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Out-of-network provider
A provider who is not an in-network provider and does not appear in the directory for your plan.
Payment Percentage
The specific percentage we have to pay for eligible dental services.
Physician
A skilled health professional trained and licensed to practice medicine under the laws of the state where they
practice, specifically, doctors of medicine or osteopathy.
Provider
A dentist, or other entity or person licensed, or certified under applicable state and federal law to provide
dental care services to you.
Recognized charge
The amount of an out-of-network provider’s charge that is eligible for coverage. You are responsible for all
amounts above what is eligible for coverage. The recognized charge may be less than the provider’s full charge.
The recognized charge depends upon the geographic area where you receive the eligible dental service. The
table below shows the method for calculating the recognized charge for specific services or supplies:
Service or supply Recognized charge
Important note: If the provider bills less than the amount calculated using the method above,
the recognized charge is what the provider bills.
Recognized charge does not apply to:
Involuntary services
Out-of-network dental emergency services
Special terms used:
Geographic area is normally based on the first three digits of the U.S. Postal Service zip codes. If we
determine we need more data for a particular service or supply, we may base rates on a wider
geographic area such as an entire state.
Involuntary services are eligible dental services that are one of the following:
-Not available from an in-network provider
-Dental emergency services
We will calculate your cost share for involuntary services in the same way as we would if you received
the services from an in-network provider.
Prevailing charge rate is the percentile value reported in a database prepared by FAIR Health, a
nonprofit company. FAIR Health changes these rates periodically. We update our systems with these
changes within 180 days after receiving them from FAIR Health. If the FAIR Health database becomes
unavailable, we have the right to substitute a different database that we believe is comparable.
Get the most value out of your benefits:
We have online tools to help you decide the type of care to get and where. Our self-service website
offers tools to help you determine the cost of eligible dental services, compare in-network
providers and schedule office visits with them. See the How to contact us for help section for the
website.
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Teledentistry
A consultation between you and a dental provider who is performing a clinical dental service.
Services can be provided by:
Two-way audiovisual teleconferencing
Any other method permitted by state law
Temporomandibular joint dysfunction/disorder (TMJ)
This is:
A TMJ or any similar disorder of the jaw joint
A myofascial pain dysfunction (MPD) of the jaw
Any similar disorder in the relationship between the jaw joint and the related muscles and nerves
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Discount programs
We can offer you discounts on health care related goods or services. Sometimes, other companies provide these
discounted goods and services. These companies are called “third party service providers”. These third party
service providers may pay us so that they can offer you their services.
Third party service providers are independent contractors. The third party service provider is responsible for the
goods or services they deliver. We have the right to change or end the arrangements at any time.
These discount arrangements are not insurance. We don’t pay the third party service providers for the services
they offer. You are responsible for paying for the discounted goods or services.
Wellness and other rewards
You may be eligible to earn rewards for completing certain activities that improve your health, coverage and
experience with us. We may encourage you to access certain dental services or categories of dental providers,
participate in programs, including but not limited to financial wellness programs, utilize tools, improve your
health metrics or continue participation as an Aetna member through incentives. We may provide incentives
based on your participation and outcomes such as:
Modifications to copayment, deductible or payment percentage amounts
Merchandise
Coupons
Gift or debit cards
Any combination of the above
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Additional Information Provided by
SUEZ Water Resources Inc.
The following information is provided to you in accordance with the Employee Retirement Income Security Act
of 1974 (ERISA).
Name of Plan:
SUEZ Water Resources Inc. Welfare Plan
Employer Identification Number:
71-0005226
Plan Number:
501
Type of Plan:
Welfare
Type of Administration:
Administrative Services Contract with:
Aetna Life Insurance Company
151 Farmington Avenue
Hartford, CT 06156
Plan Administrator:
SUEZ Water Resources Inc.
461 From Road, Suite 400
Paramus, NJ 07652
Telephone Number: [phone]
Agent For Service of Legal Process:
SUEZ Water Resources Inc.
461 From Road, Suite 400
Paramus, NJ 07652
Service of legal process may also be made upon the Plan Administrator
End of Plan Year:
December 31
Source of Contributions:
Employer and Employee
Procedure for Amending the Plan:
The Employer may amend the Plan from time to time by a written instrument signed by the person designated
by the Plan Administrator.
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ERISA Rights
As a participant in the group benefit plan you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974. 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
and union halls, all documents governing the Plan, including insurance contracts, collective bargaining
agreements, and a copy of the latest annual report (Form 5500 Series) that is filed by the Plan with the U.S.
Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security
Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the
Plan, including insurance contracts, collective bargaining agreements, and copies of the latest annual report
(Form 5500 Series), and an updated Summary Plan Description. The Administrator may make a reasonable
charge for the copies.
Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish
each participant with a copy of this summary annual report.
Receive a copy of the procedures used by the Plan for determining a qualified domestic relations order (QDRO)
or a qualified medical child support order (QMCSO).
Continue Group Health Plan Coverage
Continue health care coverage for yourself, your spouse, or your 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 for the rules governing your COBRA
continuation coverage rights.
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 your interest and that of other plan participants and beneficiaries.
No one, including your employer, your union, 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.
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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 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 materials
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 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 status of a
domestic relations order or a medical child support order, you may file suit in a 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, you should contact:
the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your
telephone directory; or
the Division of Technical Assistance and Inquiries, Employee Benefits Security 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 Employee Benefits Security Administration.
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Continuation of Coverage During an Approved Leave of Absence Granted to Comply With Federal
Law
This continuation of coverage section applies only for the period of any approved family or medical leave
(approved FMLA leave) required by Family and Medical Leave Act of 1993 (FMLA). If your Employer grants you
an approved FMLA leave for a period in excess of the period required by FMLA, any continuation of coverage
during that excess period will be subject to prior written agreement between Aetna and your Employer.
If your Employer grants you an approved FMLA leave in accordance with FMLA, you may, during the continuance
of such approved FMLA leave, continue Health Expense Benefits for you and your eligible dependents.
At the time you request the leave, you must agree to make any contributions required by your Employer to
continue coverage. Your Employer must continue to make premium payments.
If Health Expense Benefits has reduction rules applicable by reason of age or retirement, Health Expense
Benefits will be subject to such rules while you are on FMLA leave.
Coverage will not be continued beyond the first to occur of:
The date you are required to make any contribution and you fail to do so.
The date your Employer determines your approved FMLA leave is terminated.
The date the coverage involved discontinues as to your eligible class. However, coverage for health expenses
may be available to you under another plan sponsored by your Employer.
Any coverage being continued for a dependent will not be continued beyond the date it would otherwise
terminate.
If Health Expense Benefits terminate because your approved FMLA leave is deemed terminated by your
Employer, you may, on the date of such termination, be eligible for Continuation Under Federal Law on the
same terms as though your employment terminated, other than for gross misconduct, on such date. If the group
contract provides any other continuation of coverage (for example, upon termination of employment, death,
divorce or ceasing to be a defined dependent), you (or your eligible dependents) may be eligible for such
continuation on the date your Employer determines your approved FMLA leave is terminated or the date of the
event for which the continuation is available.
If you acquire a new dependent while your coverage is continued during an approved FMLA leave, the
dependent will be eligible for the continued coverage on the same terms as would be applicable if you were
actively at work, not on an approved FMLA leave.
If you return to work for your Employer following the date your Employer determines the approved FMLA leave
is terminated, your coverage under the group contract will be in force as though you had continued in active
employment rather than going on an approved FMLA leave provided you make request for such coverage within
31 days of the date your Employer determines the approved FMLA leave to be terminated. If you do not make
such request within 31 days, coverage will again be effective under the group contract only if and when Aetna
gives its written consent.
If any coverage being continued terminates because your Employer determines the approved FMLA leave is
terminated, any Conversion Privilege will be available on the same terms as though your employment had
terminated on the date your Employer determines the approved FMLA leave is terminated.
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Page 1 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2023 - 12/31/2023
SUEZ Water Inc.: Choice Fund Open Access Plus HSA Coverage for: Individual/Individual + Family | Plan Type: OAP
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is
only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at www.cigna.com/sp. For general
definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You
can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.
Important Questions Answers Why This Matters:
What is the overall
deductible?
For in-network providers: $2,500/individual - employee only or
$5,000/family maximum (no more than $3,000 per individual -
within a family)
For out-of-network providers: $5,000/individual - employee only
or $7,500/family maximum (no more than $5,000 per individual -
within a family)
Combined medical/behavioral and pharmacy deductible
Generally, you must pay all of the costs from providers up to the
deductible amount before this plan begins to pay. If you have
other family members on the plan, each family member must
meet their own individual deductible until the total amount of
deductible expenses paid by all family members meets the
overall family deductible.
Are there services covered
before you meet your
deductible?
Yes. In-network preventive care & immunizations.
This plan covers some items and services even if you haven’t yet
met the deductible amount. But a copayment or coinsurance may
apply. For example, this plan covers certain preventive services
without cost-sharing and before you meet your deductible. See a
list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles
for specific services?No.You don't have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
For in-network providers: $5,000/individual - employee only or
$10,000/family maximum (no more than $5,000 per individual -
within a family)
For out-of-network providers: $10,000/individual - employee only
or $20,000/family maximum (no more than $10,000 per individual
- within a family)
Combined medical/behavioral and pharmacy out-of-pocket limit
The out-of-pocket limit is the most you could pay in a year for
covered services. If you have other family members in this plan,
they have to meet their own out-of-pocket limits until the overall
family out-of-pocket limit has been met.
What is not included in the
out-of-pocket limit?
Penalties for failure to obtain pre-authorization for services,
premiums, balance-billing charges, and health care this plan
doesn’t cover.
Even though you pay these expenses, they don't count toward
the out-of-pocket limit.
VEO-W-22-02 IPUC DR 110 Attachment 3
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Page 2 of 8
Important Questions Answers Why This Matters:
Will you pay less if you use a
network provider?
Yes. See www.cigna.com or call 1-800-Cigna24 for a list of
network providers.
This plan uses a provider network. You will pay less if you use a
provider in the plan’s network. You will pay the most if you use an
out-of-network provider, and you might receive a bill from a
provider for the difference between the provider’s charge and
what your plan pays (balance billing). Be aware your network
provider might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get
services.
Do you need a referral to see
a specialist?No.You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will PayCommon
Medical Event Services You May Need In-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Limitations, Exceptions, & Other
Important Information
Primary care visit to treat an
injury or illness 15% coinsurance/visit 40% coinsurance None
Specialist visit 15% coinsurance/visit 40% coinsurance None
No charge/visit**40% coinsurance/visit None
No charge/screening**40% coinsurance/ screening None
No charge/immunizations**40% coinsurance/
immunizations NoneIf you visit a health care
provider's office or clinic Preventive care/ screening/
immunization **Deductible does not apply
You may have to pay for services that
aren’t preventive. Ask your provider if
the services needed are preventive.
Then check what your plan will pay
for.
Diagnostic test (x-ray, blood
work)15% coinsurance 40% coinsurance None
If you have a test Imaging (CT/PET scans,
MRIs)15% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
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Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important InformationIn-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Generic drugs (Tier 1)Coverage available through
Express Scripts
Coverage available through
Express Scripts
Preferred brand drugs (Tier
2)
Coverage available through
Express Scripts
Coverage available through
Express Scripts
Non-preferred brand drugs
(Tier 3)
Coverage available through
Express Scripts
Coverage available through
Express Scripts
If you need drugs to treat
your illness or condition
Prescription drug
coverage is
available through Express
Scripts. Please visit
www.express-
scripts.com or call 800-334-
8134
Specialty drugs (Tier 4)Coverage available through
Express Scripts
Coverage available through
Express Scripts
Contact Express Scripts for non-Cigna
coverage that may be available.
Facility fee (e.g.,
ambulatory surgery center)15% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.If you have outpatient
surgery Physician/surgeon fees 15% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
Emergency room care 15% coinsurance 15% coinsurance
Out-of-network services are paid at
the in-network cost share and
deductible.
Emergency medical
transportation 15% coinsurance 15% coinsurance
Out-of-network air ambulance
services are paid at the in-network
cost share and deductible.
If you need immediate
medical attention
Urgent care 15% coinsurance 40% coinsurance None
Facility fee (e.g., hospital
room)15% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.If you have a hospital stay
Physician/surgeon fees 15% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
Outpatient services
15% coinsurance/office visit
15% coinsurance/all other
services
40% coinsurance/office visit
40% coinsurance/all other
services
$750 penalty if no precert of out-of-
network non-routine services (i.e.,
partial hospitalization, etc.).
If you need mental health,
behavioral health, or
substance abuse services Inpatient services 15% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
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Page 4 of 8
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important InformationIn-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Office visits 15% coinsurance 40% coinsurance
Childbirth/delivery
professional services 15% coinsurance 40% coinsurance
If you are pregnant
Childbirth/delivery facility
services 15% coinsurance 40% coinsurance
Primary Care or Specialist benefit
levels apply for initial visit to confirm
pregnancy.
Cost sharing does not apply for
preventive services.
Depending on the type of services, a
copayment, coinsurance or deductible
may apply. Maternity care may
include tests and services described
elsewhere in the SBC (i.e.
ultrasound).
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Page 5 of 8
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important InformationIn-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Home health care 15% coinsurance 40% coinsurance
$750 penalty for no out-of-network
precertification.
Coverage is limited to 120 days
annual max.
16 hour maximum per day (The limit is
not applicable to mental health and
substance use disorder conditions.)
Rehabilitation services
15% coinsurance/PCP visit
15% coinsurance/ Specialist
visit
40% coinsurance/PCP visit
40% coinsurance/ Specialist
visit
$750 penalty for failure to precertify
out-of-network speech therapy
services. Coverage is limited to
annual max of: 60 days each for
Pulmonary rehab and Cognitive
therapy services; 60 days each for
Physical and Occupational therapies;
60 days for Speech therapy; 60 days
for Chiropractic care services
Limits are not applicable to mental
health conditions for Physical, Speech
and Occupational therapies.
If you need help
recovering or have other
special health needs
Habilitation services
15% coinsurance/PCP visit
15% coinsurance/ Specialist
visit
40% coinsurance/PCP visit
40% coinsurance/ Specialist
visit
Services are covered when Medically
Necessary to treat a mental health
condition (e.g. autism).
$750 penalty for failure to precertify
out-of-network speech therapy
services.
Limits are not applicable to mental
health conditions for Physical, Speech
and Occupational therapies.
VEO-W-22-02 IPUC DR 110 Attachment 3
Page 5 of 11
Page 6 of 8
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important InformationIn-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Skilled nursing care 15% coinsurance 40% coinsurance
$750 penalty for no out-of-network
precertification.
Coverage is limited to 120 days
annual max.
Durable medical equipment 15% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
Hospice services
15% coinsurance/inpatient;
15% coinsurance/outpatient
services
40% coinsurance/inpatient;
40% coinsurance/outpatient
services
$750 penalty for no out-of-network
precertification.
Children's eye exam Not covered Not covered None
Children's glasses Not covered Not covered NoneIf your child needs dental
or eye care Children's dental check-up Not covered Not covered None
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture
Cosmetic surgery
Dental care (Adult)
Dental care (Children)
Eye care (Children)
Hearing aids
Long-term care
Non-emergency care when traveling outside the
U.S.
Prescription drugs
Private-duty nursing
Routine eye care (Adult)
Routine foot care
Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Bariatric Surgery (in-network only)Chiropractic care (60 days)Infertility treatment (Lifetime max $15,000)
VEO-W-22-02 IPUC DR 110 Attachment 3
Page 6 of 11
Page 7 of 8
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee
Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you, too, including buying
individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-
2596.
Your Grievance and Appeals Rights:
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information
about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a
claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Cigna Customer service at 1-800-
Cigna24. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Additionally, a consumer assistance program can help you file your appeal. Contact: New Jersey Department of Banking and Insurance at [phone].
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
VEO-W-22-02 IPUC DR 110 Attachment 3
Page 7 of 11
Page 8 of 8
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)

Managing Joe's Type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)

Mia's Simple Fracture
(in-network emergency room visit and follow up
care) ■The plan's overall deductible $2,500
■ Specialist coinsurance 15%
■Hospital (facility) coinsurance 15%
■Other coinsurance 15%

■The plan's overall deductible $2,500
■ Specialist coinsurance 15%
■Hospital (facility) coinsurance 15%
■Other coinsurance 15%

■The plan's overall deductible $2,500
■ Specialist coinsurance 15%
■Hospital (facility) coinsurance 15%
■Other coinsurance 15% This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost $12,700

In this example, Peg would pay:
Cost Sharing
Deductibles $2,500
Copayments $0
Coinsurance $1,500
What isn't covered
Limits or exclusions $20
The total Peg would pay is $4,020

Total Example Cost $5,600

In this example, Joe would pay:
Cost Sharing
Deductibles $2,500
Copayments $800
Coinsurance $500
What isn't covered
Limits or exclusions $20
The total Joe would pay is $3,820

Total Example Cost $2,800

In this example, Mia would pay:
Cost Sharing
Deductibles $2,500
Copayments $0
Coinsurance $50
What isn't covered
Limits or exclusions $0
The total Mia would pay is $2,550
The plan would be responsible for the other costs of these EXAMPLE covered services.
Plan Name: HSA Plan Ben Ver: 26 Plan ID: 15552336
VEO-W-22-02 IPUC DR 110 Attachment 3
Page 8 of 11

VEO-W-22-02 IPUC DR 110 Attachment 3
Page 9 of 11

Cigna complies with applicable Federal civil rights laws and
does not discriminate on the basis of race, color, national
origin, age, disability, or sex. Cigna does not exclude people
or treat them differently because of race, color, national
origin, age, disability, or sex.
Cigna:
• Provides free aids and services to people with
disabilities to communicate effectively with us, such as:
– Qualified sign language interpreters
– Written information in other formats (large print,
audio, accessible electronic formats, other formats)
• Provides free language services to people whose
primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact customer service at
the toll-free number shown on your ID card, and ask a
Customer Service Associate for assistance.
If you believe that Cigna has failed to provide these services
or discriminated in another way on the basis of race, color,
national origin, age, disability, or sex, you can file
a grievance by sending an email to [e-mail] or by
writing to the following address:
Cigna
Nondiscrimination Complaint Coordinator
PO Box 188016
Chattanooga, TN 37422
If you need assistance filing a written grievance, please call the
number on the back of your ID card or send an email to
[e-mail]. You can also file a civil rights
complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office
for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1.800.368.1019, 800.537.7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life
Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health
Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and
other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance
services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224
(TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente
actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY
deben llamar al 711).
896375b 05/21 © 2021 Cigna.
Medical coverage
DISCRIMINATION IS AGAINST THE LAW
VEO-W-22-02 IPUC DR 110 Attachment 3
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VEO-W-22-02 IPUC DR 110 Attachment 3
Page 11 of 11
Page 1 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2023 - 12/31/2023
SUEZ Water Inc.: Open Access Plus Coverage for: Individual/Individual + Family | Plan Type: OAP
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is
only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at www.cigna.com/sp. For general
definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You
can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.
Important Questions Answers Why This Matters:
What is the overall
deductible?
For in-network providers: $300/individual or $600/family
For out-of-network providers: $750/individual or $2,250/family
Generally, you must pay all of the costs from providers up to the
deductible amount before this plan begins to pay. If you have
other family members on the plan, each family member must
meet their own individual deductible until the total amount of
deductible expenses paid by all family members meets the
overall family deductible.
Are there services covered
before you meet your
deductible?
Yes. In-network preventive care & immunizations, office visits,
emergency room visits, in-network urgent care facility visits.
This plan covers some items and services even if you haven’t yet
met the deductible amount. But a copayment or coinsurance may
apply. For example, this plan covers certain preventive services
without cost-sharing and before you meet your deductible. See a
list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles
for specific services?No.You don't have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
For in-network providers: $3,500/individual or $7,000/family
For out-of-network providers: $4,000/individual or $12,000/family
The out-of-pocket limit is the most you could pay in a year for
covered services. If you have other family members in this plan,
they have to meet their own out-of-pocket limits until the overall
family out-of-pocket limit has been met.
What is not included in the
out-of-pocket limit?
Penalties for failure to obtain pre-authorization for services,
premiums, balance-billing charges, and health care this plan
doesn’t cover.
Even though you pay these expenses, they don't count toward
the out-of-pocket limit.
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 1 of 11
Page 2 of 8
Important Questions Answers Why This Matters:
Will you pay less if you use a
network provider?
Yes. See www.cigna.com or call 1-800-Cigna24 for a list of
network providers.
This plan uses a provider network. You will pay less if you use a
provider in the plan’s network. You will pay the most if you use an
out-of-network provider, and you might receive a bill from a
provider for the difference between the provider’s charge and
what your plan pays (balance billing). Be aware your network
provider might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get
services.
Do you need a referral to see
a specialist?No.You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will PayCommon
Medical Event Services You May Need In-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Limitations, Exceptions, & Other
Important Information
Primary care visit to treat an
injury or illness
$25 copay/visit
Deductible does not apply 40% coinsurance None
Specialist visit $35 copay/visit
Deductible does not apply 40% coinsurance None
No charge/visit**40% coinsurance/visit None
No charge/screening**40% coinsurance/ screening None
No charge/immunizations**40% coinsurance/
immunizations None
If you visit a health care
provider's office or clinic
Preventive care/ screening/
immunization **Deductible does not apply
You may have to pay for services that
aren’t preventive. Ask your provider if
the services needed are preventive.
Then check what your plan will pay
for.
Diagnostic test (x-ray, blood
work)20% coinsurance 40% coinsurance None
If you have a test Imaging (CT/PET scans,
MRIs)20% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 2 of 11
Page 3 of 8
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important InformationIn-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Generic drugs (Tier 1)Coverage available through
Express Scripts
Coverage available through
Express Scripts
Preferred brand drugs (Tier
2)
Coverage available through
Express Scripts
Coverage available through
Express Scripts
Non-preferred brand drugs
(Tier 3)
Coverage available through
Express Scripts
Coverage available through
Express Scripts
If you need drugs to treat
your illness or condition
Prescription drug
coverage is
available through Express
Scripts. Please visit
www.express-
scripts.com or call 800-334-
8134
Specialty drugs (Tier 4)Coverage available through
Express Scripts
Coverage available through
Express Scripts
Contact Express Scripts for non-Cigna
coverage that may be available.
Facility fee (e.g.,
ambulatory surgery center)20% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.If you have outpatient
surgery Physician/surgeon fees 20% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
Emergency room care $150 copay/visit
Deductible does not apply
$150 copay/visit
Deductible does not apply
Per visit copay is waived if admitted.
Out-of-network services are paid at
the in-network cost share.
Emergency medical
transportation 20% coinsurance 20% coinsurance
Out-of-network air ambulance
services are paid at the in-network
cost share and deductible.
If you need immediate
medical attention
Urgent care $50 copay/visit
Deductible does not apply 40% coinsurance None
Facility fee (e.g., hospital
room)20% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.If you have a hospital stay
Physician/surgeon fees 20% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
Outpatient services
$25 copay/office visit**
20% coinsurance/all other
services
**Deductible does not apply
40% coinsurance/office visit
40% coinsurance/all other
services
$750 penalty if no precert of out-of-
network non-routine services (i.e.,
partial hospitalization, etc.).
If you need mental health,
behavioral health, or
substance abuse services
Inpatient services 20% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 3 of 11
Page 4 of 8
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important InformationIn-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Office visits 20% coinsurance 40% coinsurance
Childbirth/delivery
professional services 20% coinsurance 40% coinsurance
If you are pregnant
Childbirth/delivery facility
services 20% coinsurance 40% coinsurance
Primary Care or Specialist benefit
levels apply for initial visit to confirm
pregnancy.
Cost sharing does not apply for
preventive services.
Depending on the type of services, a
copayment, coinsurance or deductible
may apply. Maternity care may
include tests and services described
elsewhere in the SBC (i.e.
ultrasound).
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 4 of 11
Page 5 of 8
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important InformationIn-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Home health care 20% coinsurance 40% coinsurance
$750 penalty for no out-of-network
precertification.
Coverage is limited to 120 days
annual max.
16 hour maximum per day (The limit is
not applicable to mental health and
substance use disorder conditions.)
Rehabilitation services
$25 copay/PCP visit**
$35 copay/ Specialist visit**
**Deductible does not apply
40% coinsurance/PCP visit
40% coinsurance/ Specialist
visit
$750 penalty for failure to precertify
out-of-network speech therapy
services. Coverage is limited to
annual max of: 60 days each for
Pulmonary rehab and Cognitive
therapy services; 60 days each for
Physical and Occupational therapies;
60 days for Speech therapy; 60 days
for Chiropractic care services
Limits are not applicable to mental
health conditions for Physical, Speech
and Occupational therapies.
If you need help
recovering or have other
special health needs
Habilitation services
$25 copay/PCP visit**
$35 copay/ Specialist visit**
**Deductible does not apply
40% coinsurance/PCP visit
40% coinsurance/ Specialist
visit
Services are covered when Medically
Necessary to treat a mental health
condition (e.g. autism).
$750 penalty for failure to precertify
out-of-network speech therapy
services.
Limits are not applicable to mental
health conditions for Physical, Speech
and Occupational therapies.
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 5 of 11
Page 6 of 8
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important InformationIn-Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Skilled nursing care 20% coinsurance 40% coinsurance
$750 penalty for no out-of-network
precertification.
Coverage is limited to 120 days
annual max.
Durable medical equipment 20% coinsurance 40% coinsurance $750 penalty for no out-of-network
precertification.
Hospice services
20% coinsurance/inpatient;
20% coinsurance/outpatient
services
40% coinsurance/inpatient;
40% coinsurance/outpatient
services
$750 penalty for no out-of-network
precertification.
Children's eye exam Not covered Not covered None
Children's glasses Not covered Not covered NoneIf your child needs dental
or eye care Children's dental check-up Not covered Not covered None
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture
Cosmetic surgery
Dental care (Adult)
Dental care (Children)
Eye care (Children)
Hearing aids
Long-term care
Non-emergency care when traveling outside the
U.S.
Prescription drugs
Private-duty nursing
Routine eye care (Adult)
Routine foot care
Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Bariatric Surgery (in-network only)Chiropractic care (60 days)Infertility treatment (Lifetime max $15,000)
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 6 of 11
Page 7 of 8
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee
Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you, too, including buying
individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-
2596.
Your Grievance and Appeals Rights:
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information
about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a
claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Cigna Customer service at 1-800-
Cigna24. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Additionally, a consumer assistance program can help you file your appeal. Contact: New Jersey Department of Banking and Insurance at [phone].
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 7 of 11
Page 8 of 8
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)

Managing Joe's Type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)

Mia's Simple Fracture
(in-network emergency room visit and follow up
care) ■The plan's overall deductible $300
■ Specialist copayment $35
■Hospital (facility) coinsurance 20%
■Other coinsurance 20%

■The plan's overall deductible $300
■ Specialist copayment $35
■Hospital (facility) coinsurance 20%
■Other coinsurance 20%

■The plan's overall deductible $300
■ Specialist copayment $35
■Hospital (facility) coinsurance 20%
■Other coinsurance 20% This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost $12,700

In this example, Peg would pay:
Cost Sharing
Deductibles $310
Copayments $30
Coinsurance $2,400
What isn't covered
Limits or exclusions $20
The total Peg would pay is $2,760

Total Example Cost $5,600

In this example, Joe would pay:
Cost Sharing
Deductibles $170
Copayments $1,700
Coinsurance $600
What isn't covered
Limits or exclusions $20
The total Joe would pay is $2,490

Total Example Cost $2,800

In this example, Mia would pay:
Cost Sharing
Deductibles $310
Copayments $300
Coinsurance $100
What isn't covered
Limits or exclusions $0
The total Mia would pay is $710
The plan would be responsible for the other costs of these EXAMPLE covered services.
Plan Name: PPO Plan Ben Ver: 26 Plan ID: 15552334
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 8 of 11

VEO-W-22-02 IPUC DR 110 Attachment 4
Page 9 of 11

Cigna complies with applicable Federal civil rights laws and
does not discriminate on the basis of race, color, national
origin, age, disability, or sex. Cigna does not exclude people
or treat them differently because of race, color, national
origin, age, disability, or sex.
Cigna:
• Provides free aids and services to people with
disabilities to communicate effectively with us, such as:
– Qualified sign language interpreters
– Written information in other formats (large print,
audio, accessible electronic formats, other formats)
• Provides free language services to people whose
primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact customer service at
the toll-free number shown on your ID card, and ask a
Customer Service Associate for assistance.
If you believe that Cigna has failed to provide these services
or discriminated in another way on the basis of race, color,
national origin, age, disability, or sex, you can file
a grievance by sending an email to [e-mail] or by
writing to the following address:
Cigna
Nondiscrimination Complaint Coordinator
PO Box 188016
Chattanooga, TN 37422
If you need assistance filing a written grievance, please call the
number on the back of your ID card or send an email to
[e-mail]. You can also file a civil rights
complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office
for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1.800.368.1019, 800.537.7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life
Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health
Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and
other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance
services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224
(TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente
actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY
deben llamar al 711).
896375b 05/21 © 2021 Cigna.
Medical coverage
DISCRIMINATION IS AGAINST THE LAW
VEO-W-22-02 IPUC DR 110 Attachment 4
Page 10 of 11

VEO-W-22-02 IPUC DR 110 Attachment 4
Page 11 of 11
Enroll in VSP® Vision Care to get access to
savings and personalized vision care from a
VSP network doctor for you and your family.
Value and savings you love.
Save on eyewear and eye care when you see a VSP network
doctor. Plus, take advantage of Exclusive Member Extras which
provide offers from VSP and leading industry brands totaling
over $3,000 in savings.
Provider choices you want.
Maximize your benefits at a Premier Program
location, which is part of our incredible
network of doctors.
Shop online and connect your benefits.
Eyeconic® is the preferred VSP online retailer where
you can shop in-network with your vision benefits.
See your savings in real time when you shop over
70 brands of contacts, eyeglasses, and sunglasses.
Quality vision care you need.
You’ll get great care from a VSP network doctor, including a
WellVision Exam®. An annual eye exam not only helps you see
well, but helps a doctor detect signs of eye conditions and health
conditions, like diabetes and high blood pressure.
Using your benefit is easy!
Create an account on vsp.com to view your in-network coverage,
find the VSP network doctor who’s right for you, and discover
savings with exclusive member extras. At your appointment, just
tell them you have VSP.
More Ways
to Save
Extra
$20
to spend on
Featured Brands†
Enroll in VSP® Vision Care to get access to
savings and personalized vision care from a
VSP network doctor for you and your family.
Value and savings you love.
Save on eyewear and eye care when you see
a VSP network doctor. Plus, take advantage of Exclusive
Member Extras which provide offers from VSP and leading
industry brands totaling at over $3,000 in savings.
Provider choices you want.
Maximize your benefits at a Premier Program location,
including thousands of private practice doctors and over
700 Visionworks® retail locations nationwide.
Quality vision care you need.
You’ll get great care from a VSP network doctor, including a
WellVision Exam®. An annual eye exam not only helps you see
well, but helps a doctor detect signs of eye conditions and
health conditions, like diabetes and high blood pressure.
Using your benefit is easy!
Create an account on vsp.com to view your in-network
coverage, find the VSP network doctor who’s right for you,
and discover savings with Exclusive Member Extras. At your
appointment, just tell them you have VSP.
Enroll through your employer today.
Contact us: 800.877.7195 or vsp.com
More Ways
to Save
Extra
$20
to spend on
Featured Frame Brands†
See all brands and offers
at vsp.com/offers.
+
Up to
40%
Savings on
lens enhancements‡
With VSP and [Client Name], your health
comes first.
A Look
at Your VSP
Vision Coverage
and more
See all brands and offers
at vsp.com/offers.
+
Up to
40%
Savings on
lens enhancements‡
A Look
at Your VSP
Vision Coverage
With VSP and UNITED WATER, your health
comes first.
Enroll through your employer today.
Contact us: 800.877.7195 or vsp.com VEO-W-22-02
IPUC DR 110 Attachment 5
Page 1 of 2
Your VSP Vision Benefits Summary
UNITED WATER and VSP provide you with a choice of
affordable vision plans. Choose the eye care essentials,
or upgrade to give your eyes extra love.
COPAYDESCRIPTIONBENEFITCOPAYDESCRIPTIONBENEFIT
Premium Coverage with a VSP ProviderStandard Coverage with a VSP Provider
$15 for exam
and glasses
WELLVISION
EXAM
$25 for exam
and glasses
WELLVISION
EXAM
Focuses on your eyes and overall
wellness
Focuses on your eyes and overall
wellness
Every calendar year Every calendar year
$0 per
screening
ESSENTIAL
MEDICAL EYE
CARE
$0 per
screening
ESSENTIAL
MEDICAL EYE
CARE
Retinal screening for members with
diabetes
Retinal screening for members with
diabetes
$20 per
exam
$20 per
exam
Additional exams and services beyond
routine care to treat immediate issues
from pink eye to sudden changes in
vision or to monitor ongoing conditions
such as dry eye, diabetic eye disease,
glaucoma, and more.
Additional exams and services beyond
routine care to treat immediate issues
from pink eye to sudden changes in
vision or to monitor ongoing conditions
such as dry eye, diabetic eye disease,
glaucoma, and more.
Coordination with your medical
coverage may apply. Ask your VSP
doctor for details.
Coordination with your medical
coverage may apply. Ask your VSP
doctor for details.
Available as neededAvailable as needed
PRESCRIPTION GLASSESPRESCRIPTION GLASSES
Combined
with examFRAME+Combined
with examFRAME+
$220 featured frame brands allowance$170 featured frame brands allowance
$150 frame allowance $200 frame allowance
20% savings on the amount over your
allowance
20% savings on the amount over your
allowance
$80 Walmart®/Sam's Club®/Costco®
frame allowance
$110 Walmart®/Sam's Club®/Costco®
frame allowance
Every other calendar year Every calendar year
Combined
with examLENSES Combined
with examLENSES
Single vision, lined bifocal, and lined
trifocal lenses
Single vision, lined bifocal, and lined
trifocal lenses
Impact-resistant lenses for dependent
children
Impact-resistant lenses for dependent
children
Every calendar yearEvery calendar year
$0
LENS
ENHANCEMENTS
$0
LENS
ENHANCEMENTS
Standard progressive lensesStandard progressive lenses
$80 - $90 $0Premium progressive lenses Tints/Light-reactive lenses
$120 - $160 $25Custom progressive lenses Anti-glare coating
$80 - $90Average savings of 40% on other lens
enhancements
Premium progressive lenses
$120 - $160Custom progressive lenses
Every calendar year Average savings of 40% on other lens
enhancements
Up to $60
CONTACTS
(INSTEAD OF
GLASSES)
Every calendar year$175 allowance for contacts; copay does
not apply
Up to $60
CONTACTS
(INSTEAD OF
GLASSES)
$175 allowance for contacts; copay does
not apply
Contact lens exam (fitting and
evaluation)
Every calendar year Contact lens exam (fitting and
evaluation)
YOUR COVERAGE GOES FURTHER IN-NETWORK Every calendar year
YOUR COVERAGE GOES FURTHER IN-NETWORKWith so many in-network choices, VSP makes it easy to get the
most out of your benefits. You’ll have access to preferred private With so many in-network choices, VSP makes it easy to get the
most out of your benefits. You’ll have access to preferred privatepractice, retail, and online in-network choices. Log in to vsp.com to
find an in-network provider.practice, retail, and online in-network choices. Log in to vsp.com to
find an in-network provider.
Glasses and Sunglasses
EXTRA SAVINGS
Extra $20 to spend on featured frame brands. Go to vsp.com/offers for details.
30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your
WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam.
Routine Retinal Screening
No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction
Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor
PROVIDER NETWORK:
VSP Signature
EFFECTIVE DATE:
01/01/2023
†Only available to VSP members with applicable plan benefits. Frame brands and promotions are subject to change.
‡Savings based on doctor’s retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Ask your VSP network doctor for more details.
+Coverage with a retail chain may be different or not apply.
VSP guarantees member satisfaction from VSP providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract
will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business. TruHearing is not available directly
from VSP in the states of California and Washington.
©2022 Vision Service Plan. All rights reserved.
VSP, Eyeconic, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon and Dragon are registered trademarks of Marchon Eyewear, Inc. All other brands or
marks are the property of their respective owners. 102898 VCCM Classification: Restricted

VEO-W-22-02
IPUC DR 110 Attachment 5
Page 2 of 2
2023 Medical Rates
SUEZ NA: 2023 Funding, Contributions, COBRA Premiums (ALL MONTH
EMPLOYEE EMPLOYER
No COBRA count for Idaho -
of health coverage
Medical/Rx: Cigna
PPO Funding Rate EE Contribution*EE Annual Cost SUEZ Plan Cost ER Annual Cost COBRA Rate
*Assumes 6% increase to employee contributions. 13% increase to budget for medical costs
QHDP Funding Rate EE Contribution*EE Annual Cost SUEZ Plan Cost ER Annual Cost COBRA Rate
EE $721.90 $34.39 $412.68 $687.51 $8,250.12 $736.34
EE/CH $1,299.41 $68.75 $825.00 $1,230.66 $14,767.92 $1,325.40
EE/SP $1,515.98 $71.74 $860.88 $1,444.24 $17,330.88 $1,546.30
FAM $2,165.69 $102.40 $1,228.80 $2,063.29 $24,759.48 $2,209.00
*Assumes 6% increase to employee contributions. 13% increase to budget for medical costs
Medical/Rx: Kaiser (CA Work State Only)
EE $632.85 $160.96 $1,931.52 $471.89 $5,662.68 $645.51
EE/CH $1,265.69 $321.91 $3,862.92 $943.78 $11,325.36 $1,291.00
EE/SP $1,392.26 $354.10 $4,249.20 $1,038.16 $12,457.92 $1,420.11
FAM $1,898.54 $482.86 $5,794.32 $1,415.68 $16,988.16 $1,936.51
*Kaiser renewal calls for a 5% increase. No increase to EE contributions
Dental: Aetna
PPO Funding Rate*EE Contribution**EE Annual Cost SUEZ Plan Cost ER Annual Cost COBRA Rate
EE $42.26 $7.92 $95.04 $34.34 $412.08 $43.11
EE/CH $86.64 $14.86 $178.32 $71.78 $861.36 $88.37
EE/SP $90.44 $14.86 $178.32 $75.58 $906.96 $92.25
FAM $124.66 $23.59 $283.08 $101.07 $1,212.84 $127.15
*Assumes holding funding rates flat, even though projection is calling for a slight decrease of 3%.
**Assumes 0% increase to employee contributions.
DHMO Premium EE Contribution*EE Annual Cost SUEZ Plan Cost ER Annual Cost COBRA Rate
EE $23.43 $3.95 $47.40 $19.48 $233.76 $23.90
EE/CH $50.07 $7.42 $89.04 $42.65 $511.80 $51.07
EE/SP $48.07 $7.42 $89.04 $40.65 $487.80 $49.03
FAM $69.10 $11.75 $141.00 $57.35 $688.20 $70.48
* DHMO premiums for 2023 unchanged; therefore, 0% increase assumed for employee contributions.
Vision: VSP
Basic Premium EE Contribution*EE Annual Cost SUEZ Plan Cost ER Annual Cost COBRA Rate
EE $7.84 $7.84 $94.08 $0.00 $0.00 $8.00
EE/CH $13.06 $13.06 $156.72 $0.00 $0.00 $13.32
EE/SP $12.20 $12.20 $146.40 $0.00 $0.00 $12.44
FAM $20.89 $20.89 $250.68 $0.00 $0.00 $21.31
*Under rate guarantee, 0% increase to employee contributions
Buy-Up Premium EE Contribution*EE Annual Cost SUEZ Plan Cost ER Annual Cost COBRA Rate
EE $16.52 $16.52 $198.24 $0.00 $0.00 $16.85
EE/CH $27.54 $27.54 $330.48 $0.00 $0.00 $28.09
EE/SP $25.74 $25.74 $308.88 $0.00 $0.00 $26.25
FAM $44.02 $44.02 $528.24 $0.00 $0.00 $44.90
*Under rate guarantee; 0% increase to employee contributions
Medical Cost Projection REVISED
VEOLIA WATER IDAHO, INC. - Medical Benefit Costs 2023 Rates
Ratio %Proforma Employees
Medical - HDHP Employee Only 18 $687.51 $34.39 $8,250.12 $412.68 $148,502 $7,428 $155,930 14.75%20.2 166,761$ 8,342$ 175,102$ Employee + Spouse 12 $1,444.24 $71.74 $17,330.88 $860.88 $207,971 $10,331 $218,301 9.84%13.5 233,541$ 11,601$ 245,141$ Employee + Child(ren)19 $1,230.66 $68.75 $14,767.92 $825.00 $280,590 $15,675 $296,265 15.57%21.3 315,089$ 17,602$ 332,692$ Family 37 $2,063.29 $102.40 $24,759.48 $1,228.80 $916,101 $45,466 $961,566 30.33%41.5 1,028,736$ 51,056$ 1,079,792$ 86 $5,425.70 $277.28 $65,108.40 $3,327.36 $1,553,164 $78,899 $1,632,063 70.49%96.6 1,744,127$ 88,600$ 1,832,727$
Employee Only 18 $75.00 $0.00 $900.00 $0.00 $16,200 $0 $16,200 20.2 18,192$ -$ 18,192$ Employee + Spouse 12 $112.50 $0.00 $1,350.00 $0.00 $16,200 $0 $16,200 13.5 18,192$ -$ 18,192$ Employee + Child(ren)19 $112.50 $0.00 $1,350.00 $0.00 $25,650 $0 $25,650 21.3 28,804$ -$ 28,804$ Family 37 $112.50 $0.00 $1,350.00 $0.00 $49,950 $0 $49,950 41.5 56,091$ -$ 56,091$ 86 $412.50 $0.00 $4,950.00 $0.00 $108,000 $0 $108,000 95.47%96.6 121,279$ -$ 121,279$ -
Medical - PPO Employee Only 9 $627.25 $187.49 $7,527.00 $2,249.88 $67,743 $20,249 $87,992 7.38%10.1 76,072$ 22,739$ 98,811$ Employee + Spouse 6 $1,308.08 $402.88 $15,696.96 $4,834.56 $94,182 $29,007 $123,189 4.92%6.7 105,761$ 32,574$ 138,335$ Employee + Child(ren)3 $1,129.07 $337.47 $13,548.84 $4,049.64 $40,647 $12,149 $52,795 2.46%3.4 45,644$ 13,643$ 59,287$ Family 6 $1,881.77 $562.45 $22,581.24 $6,749.40 $135,487 $40,496 $175,984 4.92%6.7 152,146$ 45,475$ 197,621$ 24 $4,946.17 $1,490.29 $59,354.04 $17,883.48 $338,059 $101,902 $439,960 19.67%27.0 379,623$ 114,430$ 494,054$
12 $0 $0 $0 9.84%13.5 -$ -$ -$
TRUE
DENTAL
Dental - DMO Employee Only 3 $19.48 $3.95 $233.76 $47.40 $701 $142 $843 2.46%3.4 788$ 160$ 947$ Employee + Spouse 4 $40.65 $7.42 $487.80 $89.04 $1,951 $356 $2,307 3.28%4.5 2,191$ 400$ 2,591$ Employee + Child(ren)3 $42.65 $7.42 $511.80 $89.04 $1,535 $267 $1,803 2.46%3.4 1,724$ 300$ 2,024$ Family 8 $57.35 $11.75 $688.20 $141.00 $5,506 $1,128 $6,634 6.56%9.0 6,183$ 1,267$ 7,449$ 18 $160.13 $30.54 $1,921.56 $366.48 $9,693 $1,893 $11,587 14.75%20.2 10,885$ 2,126$ 13,012$
Dental - PPO Employee Only 22 $34.34 $7.92 $412.08 $95.04 $9,066 $2,091 $11,157 18.03%24.7 10,180$ 2,348$ 12,528$ Employee + Spouse 17 $75.58 $14.86 $906.96 $178.32 $15,418 $3,031 $18,450 13.93%19.1 17,314$ 3,404$ 20,718$ Employee + Child(ren)17 $71.78 $14.86 $861.36 $178.32 $14,643 $3,031 $17,675 13.93%19.1 16,444$ 3,404$ 19,848$ Family 36 $101.07 $23.59 $1,212.84 $283.08 $43,662 $10,191 $53,853 29.51%40.4 49,031$ 11,444$ 60,474$ 92 $282.77 $61.23 $3,393.24 $734.76 $82,789 $18,345 $101,134 75.41%103.3 92,968$ 20,600$ 113,569$ -$
NO COVERAGE 12 $0 $0 $0 9.84%13.5 -$ -$ -$
$1 $0
VISION
Vision - Basic Employee Only 12 $0.00 $7.84 $0.00 $94.08 $0 $1,129 $1,129 7.07%13.5 -$ 1,268$ 1,268$ Employee + Spouse 10 $0.00 $12.20 $0.00 $146.40 $0 $1,464 $1,464 18.18%11.2 -$ 1,644$ 1,644$ Employee + Child(ren)12 $0.00 $13.06 $0.00 $156.72 $0 $1,881 $1,881 5.05%13.5 -$ 2,112$ 2,112$ Family 23 $0.00 $20.89 $0.00 $250.68 $0 $5,766 $5,766 10.10%25.8 -$ 6,475$ 6,475$ 57 $0.00 $53.99 $0.00 $647.88 $0 $10,239 $10,239 40.40%64.0 -$ 11,498$ 11,498$
Vision - Enhanced Employee Only 11 $0.00 $16.52 $0.00 $198.24 $0 $2,181 $2,181 11.11%12.4 -$ 2,449$ 2,449$ Employee + Spouse 11 $0.00 $25.74 $0.00 $308.88 $0 $3,398 $3,398 9.09%12.4 -$ 3,815$ 3,815$ Employee + Child(ren)5 $0.00 $27.54 $0.00 $330.48 $0 $1,652 $1,652 4.04%5.6 -$ 1,856$ 1,856$ Family 14 $0.00 $44.02 $0.00 $528.24 $0 $7,395 $7,395 10.10%15.7 -$ 8,305$ 8,305$ 41 $0.00 $113.82 $0.00 $1,365.84 $0 $14,626 $14,626 34.34%46.0 -$ 16,424$ 16,424$
NO COVERAGE 24 $0.00 $0.00 $0.00 $0.00 $0 $0 $0 25.25%27.0 -$ -$ -$
TRUE
$1,999,223 $180,801 $2,180,024 91.71%8.29%2,245,029$ 203,031$ 2,448,059$ $92,483 $20,238 $112,721 82.05%17.95%103,854$ 22,726$ 126,580$ Vision costs are fully funded by employees $0 $24,865 $24,865 0.00%100.00%-$ 27,923$ 27,923$ $0 $0 $0 -$ -$ -$
Case No. VEO-W-22-02Workpaper No. 10 Sched 5
Participants - as of Employer Cost (per Employee Cost (per Annual Employer Cost Annual Annual Annual Employee
Annual Total
Annual Annual Employee
Annual Annual Employee Annual Total Annual Annual Annual Annual Employee