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Discover

Discover the Dental Insurance Plan that helps you reach new heights. Indemnity and PPO Higher Level

the Dental Insurance Plan that

helps you

Discover the Dental Insurance Plan that helps you reach new heights. Indemnity and PPO Higher Level

reach new

heights.

the Dental Insurance Plan that helps you reach new heights. Indemnity and PPO Higher Level Dental
the Dental Insurance Plan that helps you reach new heights. Indemnity and PPO Higher Level Dental
the Dental Insurance Plan that helps you reach new heights. Indemnity and PPO Higher Level Dental

Indemnity and PPO

Plan that helps you reach new heights. Indemnity and PPO Higher Level Dental Care www.denalidental.com one

Higher Level Dental Care

www.denalidental.com

one life plan

ALL OTHER STATES

Group association dental insurance under the Denali Dental plan is underwritten by Madison National Life Insurance Company, Inc. and Standard Security Life Insurance Company of New York. Madison National and Standard Security Life are members of The IHC Group, an insurance organization composed of Independence Holding Company (NYSE:IHC) and its operating subsidiaries. The IHC Group has been providing life, health and stop loss insurance solutions for nearly 30 years. For information on The IHC Group, visit www.ihcgroup.com. There is no ownership affiliation between The IHC Group and Direct Benefits for Denali Dental or Aetna.

For Individuals, Families and Seniors

DB IN WP 0412

A Dental Insurance Plan for You and Your Family

Indemnity – Choose Your Own Dentist

Covered Services

Good oral health is important. That’s why there’s Denali Dental. Don’t have employer dental coverage? No problem. Denali Dental allows you to select your own dentist, and is affordable for you and your family.

This Dental Insurance Plan helps you cover the costs of dental care. Covered dental services include exams, cleanings, fillings and extractions, as well as crowns, bridges and dentures. This policy pays you for covered dental expenses based upon a percentage of the Reasonable and Customary (R&C) fees for those covered expenses after the $100 lifetime deductible has been satisfied. These percentages are: 100% for Preventive Services, 70% for Diagnostic Services and 10% for Basic & Major Services in the 1st year. In the 2nd year of coverage, Diagnostic Services increase to 80% and 50% for Basic & Major Services. In the 3rd year Diagnostic Services increase to 90%.

Covered Services

100% 100% 100% 90% 100% 80% 70% 50% 50% 50% 10% 0% Preventive Diagnostic Services*
100% 100% 100%
90%
100%
80%
70%
50% 50%
50%
10%
0%
Preventive
Diagnostic
Services*
Services*
Basic & Major
Services*
Year 1
100%
70%
10%
Year 2
100%
80%
50%
Year 3
100%
90%
50%

Preventive Services

• Two exams per year

• Three cleanings per calendar year

Diagnostic Services

• One series of bitewing x-rays per year

• Flouride treatments limited to dependents under age 19

Basic & Major Services

• Simple extractions

• One diagnostic x-ray, full or panoramic in any 3 year period

• Oral surgery

• Endodontic treatment

• Periodontic services

• Restoration services; inlays, onlays and crowns

• Prosthetic services; bridges and dentures

• Veneers

• Endosteal implants

• Basic fillings

Benefits

Calendar Year Maximum

Lifetime Deductible

$1,500, $2,500 or $3,500 per insured $100 per person/ $300 per family

REASONABLE AND CUSTOMARY

Dental expenses are paid based on a percentage of Reasonable and Customary (R&C) fees. This means the most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the Geographic Area in which the charge is incurred. The most common charge means the lesser of:

• the actual amount charged by the provider;

• the negotiated rate;

• the usual charge which would have been made by a provider (Dentist, Hospital, etc) for the same or a comparable professional services, drugs, procedures, devices, supplies or treatment within the same Geographic Area, as determined by Us.

“Geographic Area” means the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; or a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.

APPLYING

Send all original forms to:

Direct Benefits, Inc. 325 Cedar Street Suite 800, St. Paul MN 55101 651-649-3503 / 800-620-5010 651-649-3502 fax info@directbenefits.com

Information must be postmarked by the 25th of the month to be effective by the first of the following month.

by the 25th of the month to be effective by the first of the following month.
by the 25th of the month to be effective by the first of the following month.

www.directbenefits.com

DB IN WP 0412

A Dental Insurance Plan for You and Your Family

Choose Your PPO Own Dentist

Covered Services

Good oral health is important. That’s why there’s Denali Dental. Don’t have employer dental coverage? No problem. Denali Dental allows you to select your own dentist, and is affordable for you and your family. Choose the PPO plan and save on out-of-pocket costs when visiting an in-network provider.

This Dental Insurance Plan helps you cover the costs of dental care. Covered dental services include exams, cleanings, fillings and extractions, as well as crowns, bridges and dentures. This policy pays you for covered dental expenses based upon the reimbursement schedule of the PPO network fees for those covered expenses after the $100 lifetime deductible has been satisfied. These percentages are: 100% for Preventive Services, 40% for Diagnostic Services, 20% for Basic & Major and 10% for Child Orthodontia Services in the 1st year. In the 2nd year of coverage, Diagnostic Services increase to 80%, Basic & Major Services increase to 50% and Child Orthodontia increases to 25%. In the 3rd year Diagnostic Services increase to 90%, Basic and Major increase to 60% and Child Orthodontia increases to 50%.

Preventive Services

• Two exams per year

• Three cleanings per calendar year

Diagnostic Services

• One series of bitewing x-rays per year

• Flouride treatments limited to dependents under age 19

Basic & Major Services

• Simple extractions

• One diagnostic x-ray, full or panoramic in any 3 year period

• Oral surgery

• Endodontic treatment

• Periodontic services

• Restoration services; inlays, onlays and crowns

• Prosthetic services; bridges and dentures

• Veneers

• Endosteal implants

• Basic fillings

* Plan B PPO in- and out-of-network subject to Aetna schedule. For Aetna PPO providers please visit www.Aetna.com

Benefits

Calendar Year Maximum

Lifetime Deductible

$1,500, $2,500 or $3,500 per insured $100 per person/ $300 per family

* PPO in- and out-of-network subject to Aetna schedule. For Aetna PPO providers please visit www.Aetna.com

Covered Services

100% 100% 100% 90% 100% 80% 40% 50% 60% 50% 50% 25% 20% 10% 0%
100% 100% 100%
90%
100%
80%
40%
50% 60%
50%
50%
25%
20%
10%
0%
Preventive
Diagnostic
Ortho
Services*
Services*
Basic & Major
Services*
Services*
Year 1
100%
40%
20%
10%
Year 2
100%
80%
50%
25%
Year 3
100%
90%
60%
50%

REASONABLE AND CUSTOMARY

Dental expenses are paid based on a percentage of Reasonable and Customary (R&C) fees. This means the most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the Geographic Area in which the charge is incurred. The most common charge means the lesser of:

• the actual amount charged by the provider;

• the negotiated rate;

• the usual charge which would have been made by a provider (Dentist, Hospital, etc) for the same or a comparable professional services, drugs, procedures, devices, supplies or treatment within the same Geographic Area, as determined by Us.

“Geographic Area” means the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; or a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.

APPLYING

Send all original forms to:

Direct Benefits, Inc. 325 Cedar Street Suite 800, St. Paul MN 55101 651-649-3503 / 800-620-5010 651-649-3502 fax info@directbenefits.com

Information must be postmarked by the 25th of the month to be effective by the first of the following month.

25th of the month to be effective by the first of the following month. www.directbenefits.com DB
25th of the month to be effective by the first of the following month. www.directbenefits.com DB

www.directbenefits.com

DB IN WP 0412

DB IN WP 0412

DENALI INDEMNITY MONTHLY PREMIUMS

 

Area 1

Area 2

Area 3

Area 4

Area 5

Area 6

Area 7

Area 8

Single

$24.50

$27.52

$30.25

$32.97

$35.99

$38.72

$42.35

$48.39

Single +1

$49.01

$55.04

$60.49

$65.95

$71.98

$77.43

$84.70

$96.79

Single +2 or more

$80.11

$89.98

$98.89

$107.80

$117.67

$126.58

$138.46

$158.22

Monthly rates do not include the $1 monthly, $3 quarterly, or $12 annually association fee. Choose from a $5 monthly, a $7.50 quarterly, or a $10.00 annual billing fee.

Rates are guaranteed for 12 months from effective date. Rates are good through December 1, 2012 effective dates.

 

InDEmnITY AnD PPO AREA FACTORS

 

Alabama

1

Hawaii

4

Missouri

1

Tennessee 370-372, 380-384 Texas 750, 751, 760 761, 770 772-777, 786 787, 789

1

Arizona

1

Illinois

1

630-634

2

2

850-851

2

600-608

3

640-641

2

1

852-853

3

Iowa

2

Montana

2

2

Arkansas

1

Kansas

1

Nebraska

1

2

California 6

Kentucky

1

Nevada

4

2

945-951

7

Louisiana

1

893-898

5

2

Colorado

3

Massachusetts

4

New Mexico

1

752-753

2

800-804

4

017-019

5

North Dakota

1

Utah

3

808-809

4

021-022

6

Ohio

1

Vermont

3

Connecticut 5

Michigan

2

Oklahoma

1

Virginia

1

068-069

6

480-485

3

Oregon

4

201

4

Delaware Dist of Columbia Georgia

5

Minnesota

2

970-975

5

220-223

3

4

554

4

Rhode Island

3

233-237

2

1

550-553, 555

3

South Carolina

2

West Virginia

1

301-302

3

Mississippi

1

South Dakota

1

Wisconsin

2

300, 303, 311

3

532-534, 537

3

For Aetna PPO providers, visit www.aetna.com

DB IN WP 0412

DENALI PPO MONTHLY PREMIUMS

 

Area 1

Area 2

Area 3

Area 4

Area 5

Area 6

Area 7

Area 8

Single

$20.99

$23.38

$25.54

$27.70

$30.09

$32.24

$35.11

$39.90

Single +1

$46.18

$51.45

$56.19

$60.93

$66.20

$70.92

$77.24

$87.77

Single +2 or more

$69.58

$77.51

$84.66

$91.81

$99.74

$106.86

$116.38

$132.24

Monthly rates do not include the $1 monthly, $3 quarterly, or $12 annually association fee. Choose from a $5 monthly, a $7.50 quarterly, or a $10.00 annual billing fee.

Rates are guaranteed for 12 months from effective date. Rates are good through December 1, 2012 effective dates.

 

InDEmnITY AnD PPO AREA FACTORS

 

Alabama Arizona

1

Hawaii

4

Missouri

1

Tennessee 370-372, 380-384 Texas 750, 751, 760 761, 770 772-777, 786 787, 789

1

1

Illinois

1

630-634

2

2

850-851

2

600-608

3

640-641

2

1

852-853

3

Iowa

2

Montana

2

2

Arkansas California

1

Kansas

1

Nebraska

1

2

6

Kentucky

1

Nevada

4

2

945-951

7

Louisiana

1

893-898

5

2

Colorado

3

Massachusetts

4

New Mexico

1

752-753

2

800-804

4

017-019

5

North Dakota

1

Utah

3

808-809

4

021-022

6

Ohio

1

Vermont

3

Connecticut

5

Michigan

2

Oklahoma

1

Virginia

1

068-069

6

480-485

3

Oregon

4

201

4

Delaware Dist of Columbia Georgia

5

Minnesota

2

970-975

5

220-223

3

4

554

4

Rhode Island

3

233-237

2

1

550-553, 555

3

South Carolina

2

West Virginia

1

301-302

3

Mississippi

1

South Dakota

1

Wisconsin

2

300, 303, 311

3

532-534, 537

3

For Aetna PPO providers, visit www.aetna.com

DB IN WP 0412

PLAN INfORMATION

This brochure provides a brief description of the benefits, exclusions and other provisions of the Master Group Dental Policy MNL ADEN-POL 0905 or SSL ADEN-POL 0905 issued to Communicating for America, Inc. association, the group policyholder. For complete details, please refer to the Group Dental Insurance Certificate (MNL ADEN-CER.001 0905 or SSL ADEN-CER.001 0905).

GROUP ASSOCIATION Denali Dental is a group association dental plan available to individuals and families. Membership enrollment in Communicating for America, Inc. (CA) is effective upon receipt of association dues, which are added to the plan premium. CA is a nonprofit association headquartered in Fergus Falls, Minn., providing members valued benefits and savings since 1972.

ELIGIBILITY Denali Dental is available to applicants aged 18 and older, their spouse and dependent children under the age of 26. The primary insured must be a member of CA and all family members must be residents of the United States in order to be covered.

COVERED CHARGES

Covered charges must be incurred while the policy is inforce and the person is covered by the policy. To become

a covered charge, the dental services must be performed by: a licensed dentist performing dental services within

the scope of his license; or a licensed dental hygienist acting under the supervision and direction of a dentist. A covered charge is considered incurred on the following dates: for full and partial dentures–on the date the final impression is taken; for fixed bridges, crowns, inlays and onlays–on the date the teeth are first prepared; for root canal therapy–on the date the pulp chamber is opened; for periodontal surgery–on the date surgery is performed; for all other services–on the date the service is performed.

ALTERNATIVE BENEfIT

If we determine that a less expensive alternate procedure, service or course of treatment can be performed in place

of the proposed treatment to correct a dental condition and the alternative treatment will produce a professionally satisfactory result, then the maximum we will allow will be the charge for the less expensive treatment.

PREDETERMINATION Of BENEfITS Except in an emergency, before you begin treatment that will cost more than the predetermination amount shown on the Certificate’s schedule of benefits page, your dentist must submit a claim to us describing the treatment necessary and its cost. This estimate is not a guarantee of payment. We will still consider a claim for which you have not obtained prior approval. However, the claims will be subject to reduced benefits based on our determination of reasonable and customary charges, and medically necessary treatment.

COORDINATION Of BENEfITS This plan will be coordinated with any other group, blanket or franchise plan under which an individual will receive benefits.

WAITING PERIOD TAKEOVER BENEfITS

If you were previously covered under a different dental plan with comparable coverage you may be eligible for

takeover credit under this plan at an additional cost. If your prior coverage termination date is no more than 30 days prior to the date you are requesting coverage under this plan, you are eligible for a takeover feature whereby the length of time you were covered under your prior plan will be applied to the graded benefit features of this plan. As a result, you will enter the plan at a higher level of benefit for coverage categories that grade up over time.

To qualify for this takeover feature you must provide an evidence of coverage letter from your prior carrier which includes the termination date of the prior plan and a summary of the benefits of the prior plan that illustrates prior comparable coverage. The takeover feature is available for a 20% increase to the base rate. All required information and the additional premium must be submitted with your application.

DB IN WP 0412

The following is a partial list of treatment, services or supplies, and charges that are not covered by Denali Dental:

– Treatment, services or supplies which:

- Are not medically necessary

- Are not prescribed by a dentist

- Are determined to be experimental/ investigational in nature by us

- Are received without charge or legal obligation to pay

- Would not routinely be paid in the absence of insurance

- Are received from any family member - Are not covered procedures

– Self-inflicted injuries

– War or an act or war, whether or not declared

– A covered person’s commission of a felony or an assault on another person

– Employment; whether caused by, related to, or as a condition of employment, including self-employment. This exclusion applies even if workers’ compensation or any occupational disease or similar law does not cover the charges

– Congenital or development malformations existing on the covered person’s effective date as shown in the certificate’s schedule of benefits

– Periodontal splinting

– Porcelain on crowns, or pontics posterior to the 2nd bicuspid

– Replacement of partial or full dentures, fixed or removable bridge work, crowns, gold restorations and jackets more often than once in any five-year period

– Lost, stolen or missing dentures or bridges for duplicates

– Charges payable under any medical insurance

– Charges made by any government entity, unless the covered person is required to pay, or by any public entity from which coverage could have been obtained by application or enrollment even if application or enrollment was not actually made

– Use of materials, other than fluorides or sealants, to prevent tooth decay

– Bite registrations

– Bacteriologic cultures

– Therapeutic injections administered by a dentist

– Replacement of 3rd molars

– Composites on teeth posterior to the second bicuspid

– Crowns, inlays and onlays used to restore teeth with microfractures or fracture lines, undermined cusps, or existing large restorations without overt pathology

– Temporomandibular joint syndrome

NOTICE: This brochure provides a very brief description of some important features of your Plan. It is not the Insurance Contract, nor does it represent the Insurance Contract. A full explanation of benefits, exceptions and limitations is contained in the Certificate of Insurance under Policy Forms mnL ADEn-POL 0905 and SSL ADEn-POL 0905 issued to Communicating for America.

DB IN WP 0412

Payment Information

Payment Information Higher Level Dental Care If you are not completely satisfied with this coverage, and

Higher Level Dental Care

If you are not completely satisfied with this coverage, and you have not filed a claim, you may return the Policy/ Certificate of Insurance within 10 days and receive a premium refund (minus administration fees and dues).

Please choose your payment method below and complete the payment and signature forms to complete your online application.

Credit Card Number:

Expiration:

We accept Visa, Master Card and Discover. *Monthly or annual credit card payments available.

or

Automatic Bank Withdraw By selecting Automatic Bank Withdrawal, Madison National Life Insurance Company of America's or Standard Security Life Insurance Company of New York’s monthly premium will automatically be withdrawn from your checking account at the following bank.

Name on Checking Account:

Checking Account Number:

Bank (Institution) Name:

Bank Routing Number:

I request that you pay and charge my account debits from my account by IHC Health Solutions to its order. This authorization will stay in effect until I revoke it in writing. Until you receive such notice, I agree that you shall be fully protected in honoring any such debits. I also agree that you may at any time, end this agreement by giving 30 days advanced written notice to me. You are to treat such debit as if it were signed by me. If you dishonor such debit with or without cause, I will not hold you liable even if it results in loss of my insurance.

• Automatic withdrawals to occur on the first of the month.

• The payment option you chose will continue through the duration of your coverage. If you want to change your payment option please contact IHC Health Solutions at 800-228-6790.

• My insurance will not go into effect until the application is approved and the payment is received by IHC Health Solutions. If payment is not received, my application will be considered void and no coverage will be issued.

I understand that my application is subject to approval by the issuing insurance carrier and the submission and acceptance of my credit card information does not constitute approval of or issuance of my coverage.

Signature of Applicant

Date

Agent Name

Agent Signature

Date

Direct Benefits, Inc.

325 Cedar Street, Suite 800 • St. Paul, MN 55101 651-649-3503 / 800-620-5010 • Fax: 651-649-3502

Madison National Life Insurance Company, Inc. - P.O. Box 5008, Madison, Wisconsin

PLEASE PRINT IN SPACE PROVIDED

IndemnityBox 5008, Madison, Wisconsin PLEASE PRINT IN SPACE PROVIDED PPO $1,500 max $2,500 max $3,500 max

PPOMadison, Wisconsin PLEASE PRINT IN SPACE PROVIDED Indemnity $1,500 max $2,500 max $3,500 max Higher Level

$1,500 maxWisconsin PLEASE PRINT IN SPACE PROVIDED Indemnity PPO $2,500 max $3,500 max Higher Level Dental Care

$2,500 maxPLEASE PRINT IN SPACE PROVIDED Indemnity PPO $1,500 max $3,500 max Higher Level Dental Care LAST

$3,500 maxPRINT IN SPACE PROVIDED Indemnity PPO $1,500 max $2,500 max Higher Level Dental Care LAST NAME

PROVIDED Indemnity PPO $1,500 max $2,500 max $3,500 max Higher Level Dental Care LAST NAME  

Higher Level Dental Care

LAST NAME

 

FIRST NAME

 

M.I.

 

SOCIAL SECURITY #

 

STREET ADDRESS

 

CITY

STATE

 

ZIP

TELEPHONE NUMBER (

)

 

BIRTH DATE

 

SEX

 

MARITAL STATUS

 
 

/

/

     
   

MALE

    MALE FEMALE SINGLE MARRIED

FEMALE

    MALE FEMALE SINGLE MARRIED

SINGLE

MARRIED

MARRIED

   

COVERAGE - Check Those That Apply (Note: If declining coverage(s), complete the section REFUSAL/WAIVER only

Dental Insurance

 

Self

SPOUSE

CHILDREN

REQUESTED EFFECTIVE DATE:

 

DEPENDENT INFORMATION SPOUSE NAME

 

SEX

BIRTH DATE (MM-DD-YY) /

/

 

MALE FEMALE

 

CHILD NAME

   

SEX

BIRTH DATE (MM-DD-YY)

STUDENT (Over Age 19)

 

MALE FEMALE

   

/

/

Yes

No

CHILD NAME

   

SEX

BIRTH DATE (MM-DD-YY)

STUDENT (Over Age 19)

 

MALE FEMALE

   

/

/

Yes

No

CHILD NAME

   

SEX

BIRTH DATE (MM-DD-YY)

STUDENT (Over Age 19)

 

MALE FEMALE

   

/

/

Yes

No

WILL YOU OR ANY DEPENDENT HAVE OTHER DENTAL INSURANCE COVERAGE? IF YES, PLEASE LIST THE NAME OF THE OTHER INSURANCE COMPANY AND PHONE NUMBER:

 

REFUSAL/WAIVER - Complete Only If You Are Declining Coverage For Yourself Or Any Dependent

 

I

DECLINE DENTAL COVERAGE FOR:

MYSELF

MY SPOUSE

MY CHILDREN

 

REASON FOR REFUSAL:

 

ACKNOWLEDGMENT AND AUTHORIZATION

 

I

hereby request coverage as outlined above under the Madison National Life Insurance Company, Inc. of Wisconsin

group plan offered by Denali Dental. I reserve the right to revoke or change this authorization by written notice. I declare all answers are true and complete.

 

WARNING: Any person who knowingly and with intent to defraud an insurer files an application or statement of claim containing any false, incomplete or misleading information may be guilty of insurance fraud which is a crime.

DATE

 

CITY AND STATE

 

SIGNATURE

 

MNL ADEN-MBR APP 0905

Direct Benefits, Inc.

325 Cedar Street, Suite 800 • St. Paul, MN 55101 651-649-3503 / 800-620-5010 • Fax: 651-649-3502

Higher Level Dental Care NEW APPLICATION CHECKLIST To expedite processing please confirm that the following

Higher Level Dental Care

NEW

APPLICATION

CHECKLIST

To expedite processing please confirm that the following is submitted.

Completed and Signed Applicationprocessing please confirm that the following is submitted. Takeover Credit Requested Premium Payment (Credit Card or

Takeover Credit Requestedthe following is submitted. Completed and Signed Application Premium Payment (Credit Card or Automatic Bank Withdrawal)

Premium Payment (Credit Card or Automatic Bank Withdrawal)Completed and Signed Application Takeover Credit Requested Completed and Signed Agent Information Section (when

Completed and Signed Agent Information Section (when applicable)Premium Payment (Credit Card or Automatic Bank Withdrawal) Premiums are determined by area. To determine your

Premiums are determined by area. To determine your monthly premium rate, refer to the Area Factor Chart (area factors are based on the first three digits of your home zip code).

Rate

+ $

Takeover credit (Rate x 1.20)

+ $

Association fee ($1 monthly, $3 quarterly or $12 annually)

+ $

Billing fee ($5 monthly, $7.50 quarterly or $10 annually)

+ $

TOTAL REMITTANCE

= $

After all of the information listed above is completed and signed send all original forms to:

Direct Benefits, Inc. 325 Cedar Street, Suite 800 Saint Paul, MN 55101 651.649.3503 • 800.620.5010 651.649.3502 fax info@directbenefits.com

Submission Date:

Information must be postmarked by the 25th of the month to be effective by the first of the following month.

month to be effective by the first of the following month. “Your Source for Dental, Disability,

“Your Source for Dental, Disability, Life and Vision Benefits”

325 Cedar Street, Suite 800

Saint Paul, mn 55101 • ph 651.649.3503 www.directbenefits.com

800.620.5010

fax 651.649.3502

DB IN WP 0412