Section I definitions Defined terms will appear capitalized throughout the [Certificate; Contract; Policy]. Acute



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SECTION I
Definitions
Defined terms will appear capitalized throughout the [Certificate; Contract; Policy].
Acute: The onset of disease or injury, or a change in the Member's condition that would require prompt medical attention.
Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See the Cost-Sharing Expenses and Allowed Amount section of this [Certificate; Contract; Policy] for a description of how the Allowed Amount is calculated. [If Your Non-Participating Provider charges more than the Allowed Amount, You will have to pay the difference between the Allowed Amount and the Provider’s charge, in addition to any Cost-Sharing requirements.]

{Drafting Note: Use the bracketed language for plans with an out-of-network option.}
Appeal: A request for Us to review a Utilization Review decision [or a Grievance] again.

{Drafting Note: Insert the bracketed language for group coverage. The grievance section is optional for individual coverage; however, insert the bracketed language if the grievance section is included in the contract or policy.}
Balance Billing: When a Non-Participating Provider bills You for the difference between the Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services.
[Certificate, Contract, Policy]: This [Certificate, Contract, Policy] issued by [insert dental plan name], including the Schedule of Benefits and any attached riders. [The Certificate explains the benefits available to You under the Group [Contract; Policy].]

{Drafting Note: Include the last bracketed sentence if the plan defines the certificate and the group contract; policy separately.}
Child, Children: The Subscriber’s Children, including any natural, adopted or step-children, unmarried disabled Children, newborn Children, or any other Children as described in the Who is Covered section of this [Certificate; Contract; Policy].
Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the service that You are required to pay to a Provider. The amount can vary by the type of Covered Service.
{Drafting Note: Insert the definition below for individual plans. It is optional for group plans.}

[[Contract, Policy]: The [Contract; Policy] entered into between [insert dental plan name] and the Group and any riders attached to the [Contract; Policy].]


Copayment: A fixed amount You pay directly to a Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service.
Cost-Sharing: Amounts You must pay for Covered Services, expressed as Copayments, Deductibles and/or Coinsurance.
Cover, Covered or Covered Services: The Medically Necessary services paid for, arranged, or authorized for You by Us under the terms and conditions of this [Certificate; Contract; Policy].
Deductible: The amount You owe before We begin to pay for Covered Services. The Deductible applies before any Copayments or Coinsurance are applied. The Deductible may not apply to all Covered Services. You may also have a Deductible that applies to a specific Covered Service that You owe before We begin to pay for a particular Covered Service.
Dependents: The Subscriber’s [Spouse and] Children.

{Drafting Note: Omit the reference to spouse for plans that provide pediatric dental coverage only.}
Emergency Dental Care: Emergency dental treatment required to alleviate pain and suffering caused by dental disease or trauma. Refer to the Pediatric Dental Care [and [Adult] Dental Care] section[s] of this [Certificate; Contract; Policy] for details.

{Drafting Note: Include the reference to adult dental care if the plan covers emergency dental care for adults.}
Exclusions: Dental care services that We do not pay for or Cover.
External Appeal Agent: An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law.
{Drafting Note: The definition below is optional.}

General Dentist: A dentist licensed under Title 8 of the New York State Education Law (or other comparable state law, if applicable) who is not a Specialist.
{Drafting Note: Insert the definition below for group coverage. The grievance section is optional for individual coverage; however, use the grievance definition if the grievance section is included in the contract or policy.}

[Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination.]


{Drafting Note: Insert for group coverage.}

[Group: The employer or party that has entered into an agreement with Us as a [contractholder; policyholder].]




Hospital: A short term, acute, general Hospital, which:

  • Is primarily engaged in providing, by or under the continuous supervision of Physicians, to patients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons;

  • Has organized departments of medicine and major surgery;

  • Has a requirement that every patient must be under the care of a Physician or dentist;

  • Provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.);

  • If located in New York State, has in effect a Hospitalization review plan applicable to all patients which meets at least the standards set forth in 42 U.S.C. Section 1395x(k);

  • Is duly licensed by the agency responsible for licensing such Hospitals; and

  • Is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational, or rehabilitory care.

Hospital does not mean health resorts, spas, or infirmaries at schools or camps.
Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay.
[In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider [or to a Preferred Provider]. The amount can vary by the type of Covered Service.]

{Drafting Note: Use for plans with an out-of-network option that use coinsurance for in-network care. Omit for all other coverage, such as coverage that does not have an out-of-network option or coverage that does not have a provider network.}
[In-Network Copayment: A fixed amount You pay directly to a Participating Provider [or to a Preferred Provider] for a Covered Service when You receive the service. The amount can vary by the type of Covered Service.]

{Drafting Note: Use for plans with an out-of-network option that use copayments for in-network care. Omit for all other coverage, such as coverage that does not have an out-of-network option or coverage that does not have a provider network.}
[In-Network Deductible: The amount You owe before We begin to pay for Covered Services received from Participating Providers [or Preferred Providers]. The In-Network Deductible applies before any Copayments or Coinsurance are applied. The In-Network Deductible may not apply to all Covered Services. You may also have an In-Network Deductible that applies to a specific Covered Service that You owe before We begin to pay for a particular Covered Service.]

{Drafting Note: Use for plans with an out-of-network option that use deductibles for in-network care. Omit for all other coverage, such as coverage that does not have an out-of-network option or coverage that does not have a provider network.}
[In-Network Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services received from Participating Providers [or Preferred Providers]. This limit never includes Your Premium or services We do not Cover. [The In-Network Out-of-Pocket Limit only applies to benefits that are part of the pediatric dental essential health benefit.]]

{Drafting Note: Use for plans with a separate out-of-network out-of-pocket limit. Include the last bracketed sentence if the out-of-pocket limit only applies to the pediatric dental essential health benefit. Omit for all other coverage, such as coverage that does not have an out-of-network option or coverage that does not have a provider network.}
Medically Necessary: See the How Your Coverage Works section of this [Certificate; Contract; Policy] for the definition.
Medicare: Title XVIII of the Social Security Act, as amended.
Member: The Subscriber or a covered Dependent for whom required Premiums have been paid. Whenever a Member is required to provide a notice, “Member” also means the Member’s designee.
[New York State of Health (“NYSOH”): The New York State of Health, the Official Health Plan Marketplace. The NYSOH is a marketplace where individuals, families and small businesses can learn about their health insurance options; compare plans based on cost, benefits and other important features; apply for and receive financial help with premiums and cost-sharing based on income; choose a plan; and enroll in coverage. The NYSOH also helps eligible consumers enroll in other programs, including Medicaid, Child Health Plus, and the Essential Plan.]

{Drafting Note: Insert for plans issued inside the NYSOH and for plans that are NYSOH-certified offered outside the NYSOH.}
[Non-Participating Provider: A Provider who doesn’t have a contract with Us [or another XXX plan] to provide services to You. [You will pay more to see a Non-Participating Provider.] [The services of Non-Participating Providers are Covered only [for Emergency Dental Care] or when authorized by Us.]

{Drafting Note: Insert the applicable bracketed non-participating provider sentence, depending on whether the plan provides out-of-network coverage. Insert the “or another plan” language, along with the name of the plan if you have affiliated arrangements with other plans. Omit for coverage that does not have a provider network and is not sold with a network product.}
[Out-of-Network Coinsurance: Your share of the costs of a Covered Service calculated as a percent of the Allowed Amount for the service that You are required to pay to a Non-Participating Provider. The amount can vary by the type of Covered Service.]

{Drafting Note: Use for plans with an out-of-network option that use coinsurance for out-of-network care. Omit for all other coverage, such as coverage that does not have an out-of-network option or coverage that does not have a provider network.}
[Out-of-Network Copayment: A fixed amount You pay directly to a Non-Participating Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service.]

{Drafting Note: Use for plans with an out-of-network option that use copayments for out-of-network care. Omit for all other coverage, such as coverage that does not have an out-of-network option or coverage that does not have a provider network.}
[Out-of-Network Deductible: The amount You owe before We begin to pay for Covered Services received from Non-Participating Providers. The Out-of-Network Deductible applies before any Coinsurance or Copayments are applied. The Out-of-Network Deductible may not apply to all Covered Services. You may also have an Out-of-Network Deductible that applies to a specific Covered Service that You owe before We begin to pay for a particular Covered Service.]

{Drafting Note: Use for plans with an out-of-network option that use deductibles for out-of-network care. Omit for all other coverage, such as coverage that does not have an out-of-network option or coverage that does not have a provider network.}
[Out-of-Network Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services received from Non-Participating Providers. This limit never includes Your Premium, Balance Billing charges or services We do not Cover. You are also responsible for all differences, if any, between the Allowed Amount and the Non-Participating Provider's charge for out-of-network services regardless of whether the Out-of-Pocket Limit has been met.]

{Drafting Note: Use for plans with a separate out-of-network out-of-pocket limit. Omit for all other coverage, such as coverage that does not have an out-of-network option or coverage that does not have a provider network.}
Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services. This limit never includes Your Premium, Balance Billing charges or the cost of dental care services We do not Cover. [The Out-of-Pocket Limit only applies to benefits that are part of the pediatric dental essential health benefit.]

{Drafting Note: Include the last bracketed sentence if the out-of-pocket limit only applies to the pediatric dental essential health benefit.}
[Participating Provider: A Provider who has a contract with Us [or another XXX plan] to provide services to You. A list of Participating Providers and their locations is available on Our website [at XXX] or upon Your request to Us. The list will be revised from time to time by Us. [You will pay higher Cost-Sharing to see a Participating Provider as compared to a Preferred Provider[, but less than if You received Covered Services from a Non-Participating Provider].]]

{Drafting Note: Insert the “or another plan” language, along with the name of the plan if you have affiliated arrangements with other plans. Insert the last sentence for tiered networks. Insert bracketed language in the last sentence if the plan offers out-of-network coverage. Omit for coverage that does not have a provider network and is not sold with a network product.}
Physician or Physician Services: Health care services a licensed medical Physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Plan Year: [The 12-month period beginning on the effective date of the [Certificate; Contract; Policy] or any anniversary date thereafter, during which the [Certificate; Contract; Policy] is in effect.] [A calendar year ending on December 31 of each year.]

{Drafting Note: Plans must use the first sentence for group coverage offered inside the NYSOH. Plans must use the second sentence for individual coverage offered inside the NYSOH. Plans may use either sentence for group and individual coverage offered outside the NYSOH.}
Preauthorization: A decision by Us prior to Your receipt of a Covered Service, procedure, treatment plan, or device that the Covered Service, procedure, treatment plan, or device is Medically Necessary. We indicate which Covered Services require Preauthorization in the Schedule of Benefits section of this [Certificate; Contract; Policy].
[Preferred Provider: A Provider who has a contract with Us to provide services to You at the highest level of coverage available to You. You will pay the least amount of Cost-Sharing to see a Preferred Provider.]

{Drafting Note: Use for plans that use a tiered network}
Premium: The amount that must be paid for Your dental insurance coverage.
[Premium Tax Credit: Financial help that lowers Your taxes to help You and Your family pay for private dental insurance. You can get this help if You get health insurance through the NYSOH and Your income is below a certain level. Advance payments of the tax credit can be used right away to lower Your monthly Premium.]

{Drafting Note: Insert for plans issued inside the NYSOH and for plans that are NYSOH-certified offered outside the NYSOH.}
Primary Care Dentist (“PCD”): A participating dentist who directly provides or coordinates a range of dental services for You.
Provider: An appropriately licensed, registered or certified dentist, dental hygienist, or dental assistant under Title 8 of the New York State Education Law (or other comparable state law, if applicable) that the New York State Insurance Law requires to be recognized who charges and bills patients for Covered Services. The Provider’s services must be rendered within the lawful scope of practice for that type of Provider in order to be Covered under this [Certificate; Contract; Policy].
Referral: An authorization given to one Participating Provider from another Participating Provider (usually from a PCD to a Specialist) in order to arrange for additional care for a Member. [A Referral can be transmitted electronically [or by Your Provider completing a paper Referral form].] [Except as provided in the Access to Care and Transitional Care section of this [Certificate; Contract; Policy] [or as otherwise authorized by Us,] a Referral will not be made to a Non-Participating Provider.] [A Referral is not required but needed in order for You to pay the lower Cost-Sharing for certain services listed in the Schedule of Benefits section of this [Certificate; Contract; Policy].]

{Drafting Note: Insert second, third and fourth sentences as applicable. Insert the reference to paper referral forms if the plan accepts paper referrals. The bracketed “or as otherwise authorized by us” language is optional. Omit for coverage that does not have a provider network.}
[Responsible Adult: The person who enters into this [Certificate; Contract; Policy] with Us on behalf of his or her Child or Children.]

{Drafting note: Use for plans that provide pediatric dental coverage only.}
Schedule of Benefits: The section of this [Certificate; Contract; Policy] that describes the Copayments, Deductibles, Coinsurance, Out-of-Pocket Limits, [Preauthorization requirements,] [Referral requirements,] and other limits on Covered Services.
Service Area: The geographical area, designated by Us and approved by the State of New York, in which We provide coverage. Our Service Area consists of: [XXX; all counties within New York State].

{Drafting Note: Insert list of the counties in the plan’s service area or all counties within New York State if applicable}
Specialist: A dentist who focuses on a specific area of dentistry, including oral surgery, endodontia, periodontia, orthodontia and pediatric dentistry, or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.
Spouse: The person to whom the Subscriber is legally married, including a same sex Spouse. [Spouse also includes a domestic partner].

{Drafting Note: For group coverage, insert the domestic partner language if the group provides coverage for domestic partners in the base contract or policy. For individual coverage, insert the domestic partner language.}
Subscriber: The person to whom this [Certificate; Contract; Policy] is issued. [In the case of a [Certificate; Contract; Policy] that provides coverage for Pediatric Dental Care only, the Subscriber refers to the Responsible Adult if the Member is under 18 years of age.]

{Drafting Note: Insert the last bracketed sentence if the plan offers coverage of pediatric dental care only.}
UCR (Usual, Customary and Reasonable): The cost of a dental service in a geographic area based on what Providers in the area usually charge for the same or similar medical service.
Us, We, Our: [Insert dental insurer name] and anyone to whom We legally delegate performance, on Our behalf, under this [Certificate; Contract; Policy].
Utilization Review: The review to determine whether services are or were Medically Necessary or experimental or investigational (including treatment for a rare disease or a clinical trial).
You, Your: The Member.


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