Microsoft Word - Dental Insurance

DENTALINSURANCE

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Startingin2024,UniversityofNebraskaDentalInsurancewillbeadministeredbyBlueCrossandBlueShield

ofNebraska.Pleasevisitnebraskablue.com/unsystemorcall866‐926‐1498formoreinformation.

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Eligibility

Employee

Facultyandstaffareeligibleforgroupdentalinsurancecoverageiftheyareemployedina"Regular”position

withanFTEof.5orgreaterorina"Temporary”po sitionformorethansixmonthswithanFTEof.5orgreater.

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Dependents

Spouse

 Husbandorwife,asrecognizedunderthelawsofthestateofNebraska

 Common‐lawspouseifthecommon‐lawmarriagewascontractedinajurisdictionrecognizingacommon‐

lawmarriage

Child

Thefollowingdependentchildrenmaybeeligibleforcoverage:

 Natural‐bornorlegallyadoptedchildwhohasnotreachedthelimitingageof26

 Stepchildwhohasnotreachedthelimitingageof26

 Childforwhomtheemployeehaslegalguardianshipandwhohasnot reachedthelimitingageof26

 Childwithamentalorphysicaldisabilitywhohasattainedthelimitingageof26maycontinuecoverage

beyondage26ifproofofdisabilityisprovidedwithin31daysofattainingage26

DependentchildrenwhoareemployedattheUniversityofNebraskainabenefits‐eligiblepositionmay

not

becoveredasadependentontheirparents’dentalinsurancepolicyprovidedthroughtheuniversity.

Coverageendswhenthedependentchildturnsage26.

EmployeePlusOne

UniversitybenefitseligibilityisextendedtoanAdultDesigneeofthesameoroppositegenderwhomeetsall

thefollowingcriteria:

 Hasresidedinthesameresidenceastheemployeeforatleastthepastconsecutive12monthsand

intendstoremainso indefinitely;

 Isatleast19yearsold;

 Isdirectlydependentupon,orinterdependentwith,theemployee,sharingacommonfinancialobligation

thatcanbedocumentedinamannerprescribedbytheuniversity;and

 Isnotcurrentlymarriedtoorlegallyseparatedfromanotherindividualundereitherstatutoryorcommon

law

.

AdditionalEmployeePlusOneinformationmaybefoundattheEmployeePlusOnebenefitsmodule.

DisabledDependentChildCoverageEligibility

Aphysicallyormentallydisabledchildmayremainaneligibledependentchilduponreachingage26if

incapableofself‐sustainingemploymentbyreasonofmentalorphysicalhandicap,anddependentuponyou

forsupportandmaintenance.Theapplicationforsuchcoveragemustbereceivedwithin31daysofthe

dependent's

26thbirthdayandthedependentmustmeetallothergroupcovera geeligibilityrequirements.

InitialEnrollment

Employeesmustenrollforcoveragewithin31daysofthedateofhireorbenefitseligibilitydate(datethe

employeesatisfiesthecriteriatobebenefits‐eligible).The31‐dayperiodisnotbasedontheemployee’s

effectivedateofcoverage.

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Enrollmentaftertheinitial31‐dayperiodislimitedto

theannualNUFlexenrollmentorwhenaPermitted

ElectionChangeEventoccurs.

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Employeesanddependentsmayenrollforcoveragewithoutproofofinsurabilityorpre‐existingcondition

limitation.

EffectiveDateofCoverage

Coverageiseffectiveonthefirstdayofthemonthfollowingtheemployee'sdateofhireoreligibility.

Coverageforemployeeshiredonthefirstdayofthemonthwillbeeffectiveonthefirstdayofthemonth.

Coverageforemployeeshiredonthefirstworkingday ofthemonth

willbeeffectiveontheactualdateofhire

(iffirstworkingdayisJan.5,coveragewillbeeffectiveJan.5).

ChangeinStatusGuidelines

Employeesmayenroll,disenrollorchangetheirdentalinsurancecoveragecategoryduringthecalendaryear

whenaPermittedElectionChangeEventoccurs.

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Employeesmustenrollormakechangesincoveragewithin31daysofthePermittedElectionChangeEvent.

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ListedbelowareseveralPermittedElectionChangeEventsthatmayallow

anemployeetoinitiateamidyear

dentalinsurancecoveragechange.

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 Changeinlegalmaritalstatus

 Changeinnumberofdependentchildren

 Changeinemploymentstatusorworkschedulethatresultsinagainorlossofcoverageeligibility

 Changeincoverageunderspouse’semployer’sbenefitsplan,ifsubstantial

RequiredDocumentationforStatusChanges

Youwillbeaskedtosupplyevidenceofeligibilityforeachdependentyouareenrollinginthedentalplan.The

typeofevidencerequiredwillvarydependingontherelationshipofthedependenttoyou,butmayinclude

birthcertificates,marriagelicensesandotherdocumentation.

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CoverageEffectiveDateasaResultofaPermittedElectionChangeEvent

CoveragechangesduetoaPermittedElectionChangeEvent aregenerallyeffectiveonthefirstdayofthe

monthfollowingthedateofthechange.However,changesthatoccuronthefirstdayofthemonthwillbe

effectiveimmediately.TheemployeemustprovideappropriatedocumentationtoverifythePermitted

ElectionChangeEvent.

BirthofaDependentChild

Coveragechangesduetoabirthofachildwillbeeffectiveonthedependent’sdateofbirth.Theapplicable

premiumwillbeginonthefirstdayofthemonthfollowingthedateofbirth.Theemployeemustprovide

appropriatedocumentationtoverifythePermittedElectionChangeEvent.

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Dentalcoveragefor

anewbornchildwillbeginatthedependentchild’sdateofbirth.Tocontinuethechild’s

coveragebeyond31days,thecoveredemployeemustcontacttheCampusBenefitsOfficewithin60days

ofadependent’sdateofbirthtoaddthenewbornchildtohisorherdentalinsurancepolicy.

The

employeemustcompleteanddelivertotheCampusBenefitsOfficeaDependentInformationRequestForm

toaddthenewdependentchildtothemedicalinsurancepolicyevenifheorsheiscurrentlyenrolledfor

Employee&ChildorEmployee&Familycoverage.Ifthenewbornchildisadded,the

coveragechangeand

relatedincreaseinpremiumswillbeeffectivethefirst ofthemonthfollowingthedependent’sdateofbirth.If

theemployeedoesnotcompleteanddelivertheproperlycompletedDependentInformation RequestForm

totheCampusBenefitsOfficewithin60daysofthenewborn’sbirthandthen

wantstocoverthechild,the

childwillbeconsideredalateenrolleeandbenefitswillnotbeprovidedtothechilduntilthenextannual

NUFlexenrollment.(NocoveragechangesareallowedasaresultofaPermittedElectionChangeEvent.)

Donotdelaycompletingandsubmittingthisformwhile

thenewbaby’sSocialSecurityNumberispend ing.

Submittheformandthenemailyourdependent’sSocialSecurityNumbertotheCampusBenefitsOfficeas

soonasitisissued.

AdoptionorLegalGuardianship

Coveragechangesduetoadependentchildwhoisaddedasaresultofadoptionorlegalguardianshipwill

coincidewiththeearlierof:1)thedateofplacementforadoption,or2)thedateofentryofanordergranting

legalguardianshiporcustodyofthechild.Placementgenerallymeans

whentheadoptiveparentshavetaken

legalresponsibilityforthechild.Premiumswillbeginonthefirstdayofthemonthfollowingtheevent.The

employeemustprovideappropriatedocumentationtoverifythePermittedElectionChangeEvent.Coverage

foradependentchild’sbabymaybeaddedtotheemployee’s(grandparents’)

dentalinsurancepolicyonlyif

employeeobtains1)legalguardianship,or2)adoptionofthenewbornchild

.

Marriage

Coveragechangesduetomarriagewillbeeffectiveonthefirstdayofthemonthfollowingthedateof

marriage.Changesincoverageforamarriageoccurringonthefirstdayofthemonthwillbeeffective

immediately.TheemployeemustprovideappropriatedocumentationtoverifythePermittedElection

ChangeEvent.

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DivorceorLegalSeparation 

CoveragechangesduetoaNebraskadivorcewillbeeffectivethefirstdayofthemonthfollowingthedatethe

divorcedecreeisentered.CoveragechangesduetoaNebraskalegalseparationwillbeeffectivethefirstday

ofthemonthfollowingthedateofthecourtorderorseparationagreement.



CoveragechangesduetoanIowadivorcewillbeeffectivethefirstdayofthemonthfollowingthedatethe

divorcedecreeisfinal.CoveragechangesduetoanIowalegalseparationwillbeeffectivethefirstdayofthe

monthfollowingthedateofthecourtorderorseparation

agreement.



Theemployeemustprovideappropriatedocumentation toverifythePermittedElection ChangeEvent.

TerminationofCoverage

Coverageterminatesonthelastdayofthemonthfollowingthedateofterminationordatetheemployeeis

nolongereligibleforcoverage.Ifthedateofterminationoremployee’scoverageineligibilityisthelastdayof

themonth,coveragewillterminateimmediately.

LeaveofAbsence

Employeesmaycontinuedentalinsurancecoveragewhileonanapprovedleaveofabsenceforuptotwo

years.TheemployeeshouldcontacttheCampusBenefitsOfficetoestablishthedirectbillpremiumpaym ent

process

.

ActiveMilitaryDutyLeaveofAbsence

Anemployeewhocommencesaleaveofabsenceforactivedutyinthemilitarymaycanceldentalinsurance

coverageduringtheleave.Uponreturnfromactiveduty,theemployeemayre‐enrollfordentalinsurance

coveragewithoutproofofinsurability.Theemployeemust provideappropriatedocumentationtosupport

thedatemilitary

serviceended.

AnnualNUFlexEnrollment

EmployeesmaychangeadentalplanoptionorcoveragecategoryduringtheannualNUFlexenrollment.

ProofofinsurabilityisnotrequiredtoenrollduringtheannualNUFlexenrollment.

COBRAContinuationofCoverage

COBRAcoverageisacontinuationofPlancoveragewhencoveragewouldotherwiseendbecauseofalife

eventknownasa"qualifyingevent."COBRAcontinuationcoverageisofferedtoeachpersonwhoisa

"qualifiedbeneficiary."AqualifiedbeneficiaryissomeonewhowilllosecoverageunderthePlansbecauseof

qualifyingevent.Dependingonthetypeofqualifyingevent,employees,spousesofemployees,and

dependentchildrenofemployeesmaybequalifiedbeneficiaries.UnderthePlans,qualifiedbeneficiarieswho

electCOBRAcontinuationcoveragemustpayforCOBRAcontinuationcoverage.



Ifyouareanemployee,youwillbecomeaqualifiedbeneficiaryif

youlosecoverageunderthePlansbecause

ofeitheroneofthefollowingqualifyingevents:



(1) Yourhoursofemploymentarereduced;or

(2) Youremploymentendsforanyreasonotherthangrossmisconduct.



Ifyouarethespouseofanemployee,youwillbecomeaqualifiedbeneficiaryifyoulosecoverageunderthe

Plansbecauseofanyofthefollowingqualifyingevents:



(1) Your

spousedies;

(2) Yourspouse'shoursofemploymentarereduced;

(3) Yourspouse'semploymentendsforanyreasonotherthangrossmisconduct;or

(4) Youbecomedivorced[orlegallyseparated]fromyourspouse.Ifanemployeecancelscoverageforhisor

herspouseinanticipationofadivorce[orlegalseparation]

andadivorce[orlegalseparation]lateroccurs,

thenthedivorce[orlegalseparation]willbeconsideredaqualifyingeventeventhoughtheex‐spouselost

coverageearlier.Iftheex‐spousenotifiestheCOBRAPlanAdministratorwithin60daysofthedecreeof

dissolutionofmarriagedateandcan

establishthattheemployeecanceledthecoverageearlierin

anticipationofthedivorce[orlegalseparation],thenCOBRAcoveragemaybeavailablefortheperiod

afterthedivorce[orlegalseparation].



Yourdependentchildrenwillbecomequalifiedbeneficiariesiftheylosecover ageunderthePlansbecauseof

anyofthe

followingqualifyingevents:



(1) Theparent‐employeedies;

(2) Theparent‐employee'shoursofemploy mentarereduced;

(3) Theparent‐employee'semploymentendsforanyreasonotherthangrossmisconduct;

(4) Theparentsbecomedivorced[orlegallyseparated] ;or

(5) Thechildstopsbeingeligibleforcoverageundertheplanas

a"dependentchild."



ThePlansofferCOBRAcontinuationcoveragetoqualifiedbeneficiariesonlyaftertheCOBRAPlan

Administratorhasreceivedtimelynoticethataqualifyingeventhasoccurred,includingtheendof

employment,reductionofhoursofemployment,ordeathoftheemployee.



AdditionalCOBRAInformation

SurvivorBenefitsupontheDeathofan Employee

Thespouseofadeceasedemployeewhowasenrolledfordentalcoverageattimeofdeathmaycontinue

coveragethroughCOBRAortheretireedentalinsuranceprogramuntilhisorherdeathorremarriage.

Adependentchildofadeceasedemployeewhowasenrolledfordentalcoverageattimeofdeath

may

continuecoveragethroughCOBRAortheretireedentalinsuranceprogramifthechildhasnotreachedthe

plan’slimitingage.



A Guide to Your

University of Nebraska

Dental

(Effective Date: 01/01/2024)

98-749 1/2024

DENTAL BENEFITS

IMPORTANT TELEPHONE NUMBERS

Contacts

Member Services

Omaha and Toll-free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-866-926-1498

Coordination of Bene ts

Omaha. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .402-390-1840

Toll-free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-462-2924

Subrogation

Omaha. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .402-390-1847

Toll-free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-662-3554

Workers’ Compensation

Omaha. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .402-398-3615

Toll-free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-821-4786

98-749 1/2024

TABLE OF CONTENTS

INTRODUCTION 1

How To Use This Document 1

About Your I.D. Card 1

Schedule Of Benefits 1

THE DENTAL PLAN AND HOW IT WORKS 2

About The Plan 2

How the Network Works 2

Categories Of Dental Coverage 2

How The Plan Components Work 2

SCHEDULE OF BENEFITS SUMMARY 4

EXCLUSIONS—WHAT’S NOT COVERED 6

ELIGIBILITY AND ENROLLMENT 9

Who’s Eligible 9

Initial Enrollment 9

Special Enrollment 9

Dental Late Enrollment 9

Adding A Dependent 9

Qualified Medical Child Support Orders (QMCSO) 10

Active Employees Age 65 And Over 10

Family Medical Leave Act (FMLA) 10

CLAIM PROCEDURES 11

If You Receive Covered Services From An In-network Provider 11

Filing A Claim 11

Payment Of Benefits For Non-Contracting Provider Claims 11

Right to Amend Provider Agreements Or Benefit Payment Procedures 11

Claim Determinations 11

Explanation Of Benefits 12

APPEAL PROCEDURES 13

Appeal Procedure Definitions 13

How To Appeal An Adverse Benefit Determination 13

Internal Appeal 13

Rights To Documentation 14

COORDINATION OF BENEFITS 15

When You Have Coverage Under More Than One Plan 15

Definitions 15

Order Of Benefit Determination Rules 16

Administration Of Coordination Of Benefits 17

Miscellaneous Provisions 17

98-749 1/2024

WHEN COVERAGE ENDS 18

Continuation Of Coverage Under The Federal Continuation Law 18

What Is The Federal Continuation Law? 18

Electing COBRA Coverage 19

Termination Of COBRA Coverage 19

Uniformed Service Employment And Reemployment Rights (Military Leave) 19

Continuation Of Coverage For Children To Age 30 20

GENERAL LEGAL PROVISIONS 21

Benefit Plan Document 21

Fraud Or Misrepresentation 21

Contracting Providers 21

Subrogation 21

Contractual Right To Reimbursement 21

Workers’ Compensation 22

Legal Actions 22

DEFINITIONS 23

98-749 1/2024

INTRODUCTION

Section xWelcome

This document is your Summary Plan Description (SPD). It

describes the bene ts, exclusions and limitations of your Plan

in a general way, and is not, and should not be considered a

contract.

Your Group Dental Plan is administered in accordance with

the Administrative Services Agreement between the Group

and Blue Cross and Blue Shield of Nebraska (BCBSNE), an

independent licensee of the Blue Cross and Blue Shield

Association. The Administrative Services Agreement and

o cial Plan documents control the coverage for your Group.

NOTE: BCBSNE provides administrative claims payment services

only and does not assume any  nancial risk or obligation with

respect to claims. BCBSNE liability may occur only under a

stop loss provision, as set forth in the Administrative Services

Agreement.

How To Use This Document

For your convenience, de ned terms are capitalized throughout

this document. For an explanation of a de ned term, refer to

the Section titled “De nitions.”

Please take some time to read this document and become

familiar with it. As you read this document you will  nd that

many sections are related to other sections of the document.

You may not have all the information you need by reading

just one section. We encourage you to review the bene ts and

limitations by reading the Schedule of Bene ts Summary and

the section titled “Exclusions.”

If you have questions about your coverage or a claim, please

contact BCBSNE Member Services Department at the number

shown on your identi cation card.

About Your I.D. Card

BCBSNE will issue you an identi cation card (I.D. card). Your I.D.

number is a unique alpha numeric combination.

Present your I.D. Card to your dental provider when you

receive Services. With your BCBSNE I.D. card, most dentists and

physicians can identify your coverage and will usually submit

their claims for you.

If you want extra cards for covered family members or need

to replace a lost card, please contact BCBSNE Member

Services Department, or you may access through the website,

NebraskaBlue.com.

Schedule Of Bene ts

Your Schedule of Bene ts is a personalized document sent

by BCBSNE that provides you with a basic description of your

coverage. It also shows the membership option that applies to

you.

The Schedule of Bene ts Summary is included in this SPD. It

includes information concerning Deductible and Coinsurance

amounts, bene t limits, and coverage details. For information

which may be unique to your coverage, please refer to the

Schedule of Bene ts Summary.

How to Use This Document

98-749 1/2024

THE DENTAL PLAN AND HOW IT WORKS

Section 1

About The Plan

This Group Dental Plan is a Preferred Provider Organization

(PPO) dental bene t plan. Claims administration is provided by

Blue Cross and Blue Shield of Nebraska (BCBSNE).

BCBSNE has contracted with a panel of Dentists and Physicians

to establish a network of Providers who have agreed to furnish

services to you and your family in a manner that will help

manage costs. These providers are referred to as “In-network

Providers.”

Use of the network is voluntary, but you should be aware that

when you choose to use providers who do not participate in

the network, you can expect to pay more than your applicable

Deductible and/or Coinsurance. After this dental plan pays

its required portion of the bill, Out-of-network Providers may

bill you for any amount not paid. This balance billing does

not happen when you use In-network Providers because

these providers have agreed to accept a discounted payment

for services with no additional billing to you other than

your applicable Deductible and/or Coinsurance. In-network

Providers will also  le claims for you.

If the Out-of-network Dentist is participating with us under

another BCBSNE program, payment will be made pursuant

to that particular program. The Dentist will be reimbursed

based on the lower of the Out-of-network Allowance or

billed charges. After this plan pays its liability, you can expect

to pay your applicable Out-of-network Deductible and/or

Coinsurance. You will also be responsible for payment of any

Noncovered Services.

How the Network Works

Using Network Providers:

• Receive highest level of bene ts

• Provider  les claims for you

• Provider accepts insurance payment as payment in full

(except Deductible and /or Coinsurance amounts)

• No balance billing

Using Out-of-network Providers:

• You may be required to pay full cost at time of service

• You may be reimbursed at a lower bene t level

• You may have to  le claims

• You’re responsible for amounts that exceed the

Allowable Charge

Categories Of Dental Coverage

There are  ve major categories of dental coverage. Your dental

coverage is dependent upon which types of coverage your

employer has chosen for your group dental plan. The types of

dental coverage that you are enrolled under are indicated on

your Schedule of Bene ts Summary.

The  ve categories of dental coverage are:

• Coverage A (Preventive and Diagnostic Dentistry)

• Coverage B (Maintenance and Simple Restorative

Dentistry, Oral Surgery, Periodontic and Endodontic

Services)

• Coverage C (Complex Restorative Dentistry)

• Coverage D (Orthodontic Dentistry)

• Coverage E (Temporomandibular [Jaw] Joint

Diagnosis and Treatment)

These categories are described in more detail on your Schedule

of Bene ts Summary.

The dental bene ts available to you work together to provide

your dental care program. How bene ts are provided depends

on whether the dental service or treatment falls under Type A,

B, C, D or E coverage.

How The Plan Components Work

Your Deductible and Coinsurance are shown on your Schedule

of Bene ts Summary. The following includes an explanation of

each of those components.

Allowable Charge – An amount BCBSNE uses to calculate the

payment of Covered Services. This amount will be based on

either the Contracted Amount for In-network Providers or the

Out-of-network Allowance for Out-of-network Providers.

Coinsurance – This is the percentage you must pay for

Covered Services, after any applicable Deductible.

Be Informed

Out-of-network Providers’ charges may be higher than the

bene t amount allowed by this dental plan. You may contact

BCBSNE Member Services Department concerning allowable

bene t amounts in Nebraska for speci c dental procedures.

98-749 1/2024

Section 1

Deductible – You are responsible for certain expenses until

you reach the Plan’s Deductible, as shown on your Schedule

of Bene ts Summary. After the Deductible is met, bene ts for

Covered Services will not be subject to any further Deductible

for the rest of that Bene t Year.

Maximum Bene ts –Your Schedule of Bene ts Summary will

tell you if you have a bene t maximum for one or more types of

dental coverage and/or an overall dollar maximum bene t for

one or more types of dental coverage.

Not Medically Necessary Services – Bene ts are available

under this dental plan for Medically Necessary Services.

Services provided by all providers are subject to review

by BCBSNE. Services will not automatically be considered

Medically Necessary because they have been ordered or

provided by a Dentist or Physician. BCBSNE will determine

whether Services provided are Medically Necessary under

the terms of the Group Dental Plan, and whether bene ts

are available. When an In-network Provider is used, you are

not responsible for Services determined to be not Medically

Necessary. When Out-of-network Providers are used, you will

be responsible for Services determined to be not Medically

Necessary.

Preauthorization – Procedures intended to determine if

Services or supplies are appropriate according to the terms

of the Group Dental Plan. If Preauthorization is required for

certain Services, it will be shown on your Schedule of Bene ts

or stated in this SPD. A Dentist or Physician may also submit a

Preauthorization request to obtain a pre-treatment estimate of

bene ts.

Written requests for Preauthorization should be submitted to

the address on the back of your I.D. card. Preauthorization does

not guarantee payment, all other Plan provisions apply, for

example cost-sharing, eligibility and exclusions.

If Services are not properly Preauthorized by BCBSNE,

when required, bene ts may be reduced and/or you may

be responsible for unanticipated costs associated with the

incurred expenses.

98-749 1/2024

SCHEDULE OF BENEFITS SUMMARY

Section 2

36-054-02

98-749 1/2024

University of Nebraska Dental Option Non-Std 01-01-2024

Dental Benefit Solutions

Schedule of Benefits Summary

Group Name: University of Nebraska

Effective Date: January 01, 2024

Payment for Services

In-Network

Provider

Out-of-Network

Provider

Covered Services are reimbursed based on the Allowable Charge. BlueCross and BlueShield of Nebraska In-Network

Providers have agreed to accept the benefit payment as payment in full, not including deductible, coinsurance and/or

copay amounts and any charges for non-covered services, which are the Covered Person’s responsibility. That means that

In-Network providers, under the terms of their contract with BlueCross and BlueShield, can’t bill for amounts over the

Contracted Amount. Out-of-Network Providers can bill for amounts over the Out-of-Network Allowance.

Deductible

(the amount each Covered Person pays each Calendar

Year for combined Covered Services before the

Coinsurance is payable)

• B, C Services

$35

$45

• D Services $40 $50

Calendar Year Maximum Benefit

$1,500 $1,500

(the calendar year amount payable for combined

Covered Services for each Covered Person while

covered under this plan)

Calendar Year Maximum Benefit applies to the

following Coverage benefits:

A, B, C Services A, B, C Services

Total Maximum Benefit

$2,000 $2,000

(the total amount payable for Covered Services for each

Covered Person while covered under this plan)

Total Maximum Benefit applies to the following

Coverage benefits:

D Services D Services

Coverage A 15% 20%

Coverage B 15% 20%

Coverage C 50% 50%

Coverage D 50% 50%

Coverage E Not Covered Not Covered

Please note: This Schedule of Benefits Summary is intended to provide you with a brief overview

of your benefits. It is not a contract and should not be regarded as one. For more complete information about your

plan, including benefits, exclusions and contract limitations, please refer to the master group contract. In the event

there are discrepancies between this document and the contract, the terms and conditions of the contract will govern.

98-749 1/2024

Section 2

36-054-02

98-749 1/2024

University of Nebraska Dental Option Non-Std 01-01-2024

This Schedule of Benefits Summary is intended to provide you with a brief overview of your benefits. Your Dental benefits

may include but are not limited the following benefits.

Coverage For Dental Services

Coverage A – Preventive and Diagnostic

• Comprehensive and/or periodic oral exams

two every calendar year

• Consultations

• Prophylaxis (cleaning, scaling and polishing)

two every calendar year

• Topical fluoride

two every calendar year for Covered Persons up to age

• Sealants (permanent first and second molar teeth)

once every four calendar years for Covered Persons up

to age 16

• Pulp vitality test

• X-rays (intraoral, bitewing, occlusal, periapical,

extraoral)

− Full mouth or panorex series

one every three consecutive calendar years

− Supplemental bitewing

one set of four every calendar year

− Vertical bitewing

once every 3 years

• Space maintainers

for Covered Persons up to age 16

• Fluoride varnishes

two every calendar year

Coverage B – Maintenance, Simple Restorative, Oral Surgery, Periodontic, Endodontics

• Oral surgery

− Simple and impacted extractions

− Alveoplasty

− Removal of dental cysts and tumors

− Surgical incision and drainage of dental abscess

− Tooth replantation

− Excision of hyperplastic tissue

• General anesthesia

• Restorations, except gold restorations

• Palliative treatment

• Dry socket treatment

• Repair of dentures, bridges, crowns and cast

restorations

• Emergency oral examinations

• Pre-formed stainless steel or acrylic crowns

• Recement inlays and crowns

• Occlusal guard limited to 1 every 3 years

• Endodontic services (treatment of diseases or injuries

of pulp chambers, root canals and periapical tissue)

− Pulp cap

− Vital pulpotomy

− Root canal therapy (includes treatment plan, x-rays,

clinical procedures and follow up care)

− Apical curettage

− Root resection and hemisection

• Periodontic services (treatment of diseases of gums

and supporting tooth structure)

− Periodontic cleanings

four every calendar year

− Gingivectomy and gingival curettage limited to 1

every 3 years

− Osseous surgery and graft limited to 1 every 3 years

− Scaling and root planning Limited to 1 every 2 years

− Periodontal splinting

− Mucogingivoplastic surgery

− Treatment of acute infection and oral lesions

− Full mouth debridement limited to 1 every 5 years

Coverage C – Complex Restorative Dentistry

• Crowns

• Temporary crown (within 72 hours of accident)

• Inlays when used as abutments for fixed bridgework

• Installation of permanent bridges

• Core buildup

• Cast post and core in addition to crown

• Dentures – full and partial

• Denture adjustments

after six months from date of installation

• Denture relining

after six months from date of installation

Coverage D – Orthodontic Dentistry

• Cephalometric x-rays

• Extractions

• Casts and models

• Orthodontic appliances (initial and subsequent

installations)

• Surgical exposure to aid eruption

98-749 1/2024

EXCLUSIONSWHAT’S NOT COVERED

Section 3

The Services and supplies listed in this Section are not covered,

except where speci cally provided for on the Schedule of

Bene ts Summary or an Amendment to this SPD. Please refer

to your Schedule of Bene ts Summary, and any Amendment

to this document, for speci c information regarding your

dental Covered Services and limits.

Bene ts are not available for services that are not Covered

Services by the Plan, or services to the extent that they exceed

the Plan limitations.

Noncovered Dental Services

Noncovered Services include, but are not limited to, any

Services, procedures or supplies for, or related to:

• dental services received from a dental or medical

department maintained by or on behalf of an

employer, a mutual bene t association, labor union,

trustee or similar person or group.

• dental services with respect to congenital

malformations (including, but not limited to

missing teeth) or primarily for Cosmetic or aesthetic

purposes (except as speci cally identi ed as

Covered.) Gnathologic tests, Orthognathic Surgery,

osteoplasties, Osteotomies, LeFort procedures,

vestibuloplasties and stomatoplasties are not

Covered Services under this plan.

• appliances, devices, procedures, dentures or

restorations necessary to modify vertical dimensions

of, or restore, the Occlusion, or to replace tooth

structure lost through attrition, erosion, abrasion or

any expense for Occlusal adjustment or equilibration

(except as speci cally identi ed as covered.)

• gold restorations (except as speci cally identi ed

as covered.)

• full or partial replacement for:

- a denture replacement made necessary by reason

of the loss or theft of a denture.

- a dental appliance or prosthesis that is replaced by

reason of a loss or theft.

- crown, bridge, inlay and denture replacement

made outside the plan limits.

• caries susceptibility tests, bacteriologic studies and

histopathologic exams.

• magnetic resonance imaging and computed

tomography (CT) scans.

• replacement of third molars with prostheses.

• services for orthodontic dentistry (except as

speci cally identi ed as covered.)

• education or training in, and supplies used for dietary

or nutrition counseling, person oral hygiene or dental

plaque control.

• implants or any procedure associated with the

preparation for, maintenance of or placement or

removal of implants, except as otherwise indicated in

this plan. (Implants are de ned as arti cial material

grafted or implanted into or onto bone.)

• for any procedure begun after coverage under

this plan terminates or for any prosthetic dental

appliance installed or delivered more than 30 days

after coverage terminates.

• retreatment or adjustment, recementation, reline,

rebase, replacement or repair of cast restorations,

crowns and prostheses when made by the same

Dentist or dental o ce which provided the initial

Service, either within six months of the completion

of the Service or within any time frame, if the initial

Service is determined by us not to be adequate to

meet nationally accepted dental standards.

• duplication of x-rays.

• injectable drugs or drugs dispensed in a

provider’s o ce.

Other Plan Exclusions

Bene ts are not available for the Services, treatments or

supplies described below, even if it is recommended or

prescribed by a Physician and it is the only treatment available

for the Covered Person’s condition.

• Services determined by BCBSNE to be not payable

after a request for Preauthorization is considered.

• Services, procedures and supplies which are

determined by BCBSNE to be not Medically

Necessary.

• Services, procedures and supplies which are

considered by BCBSNE to be Investigative. In

addition, bene ts are not available for any related

services or complications.

• Services, procedures or supplies, including any

related services, which are considered to be for

Cosmetic purposes.

• Services, procedures or supplies, including any

related services, which are considered by BCBSNE to

be obsolete.

• Charges which are normally considered to be within

the charge for a service such as:

-  ling claim forms,

- furnishing any other records or information,

- special charges (i.e. dispensing fees; administrative

fees; technical support utilization review charges).

98-749 1/2024

Section 3

• Charges made separately for services, supplies or

materials when such services, supplies and materials

are considered by BCBSNE to be included within the

charge for a total service payable under the Plan, or a

charge that is payable to another provider.

• Charges made pursuant to an intentionally in icted

Injury, engaging in an illegal occupation or resulting

from commission of or attempt to commit a felony.

• Services for dental treatment whether compensated

or not, which are directly related to, or resulting from

the covered Person’s participation in a voluntary,

Investigative test or research program or study.

• Charges for services provided by a Hospital,

ambulatory surgical facility or any other facility

charge.

• Any expense for a procedure provided by a person

who is not a Dentist or dental hygienist or who is not

under the direct supervision of a Dentist.

Limitations

The following limitations are applicable except when otherwise

indicated on your Schedule of Bene ts Summary or by

amendment to this document:

• Personalized restoration or special techniques. Bene ts

provided in the construction of a denture or  xed

bridgework to replace missing teeth shall be limited

to the standard procedures for prosthetic services as

determined by BCBSNE.

• Transfer of care. When a Covered Person transfers

care during the course of treatment, or if more than

one Dentist provides services, this plan will provide

bene ts as if only one dentist has provided the

service.

• Optional techniques of treatment. When optional

techniques of treatment are used which result in a

higher charge, the plan’s liability will not exceed the

lower charge.

• Exam limit. When an initial or periodic oral exam is

performed during the same visit, bene ts for exams

shall be limited to one exam per day.

• Missed appointment charges.

• Services provided to:

- a dependent of a Covered Person who has a single

membership;

- any person who does not qualify as an Eligible

Dependent;

- any Covered Person before his or her e ective

date of coverage, or after the e ective date of

cancellation or termination of this coverage.

• Interest, sales or other taxes or surcharges.

(This includes taxes or surcharges levied by the

governmental bodies or subdivisions who do not

have jurisdiction over the Plan.)

• Services for Illness or Injury caused directly or

indirectly by war or any act of war, declared or

undeclared, or sustained while performing military

service.

• Services provided in or by:

- a Veterans Administration Hospital where the care

is for a condition related to military service; or

- any Out-of network Hospital or other institution

or facility which is owned, operated or controlled

by any government agency, except where care is

provided to nonactive duty Covered Persons in

medical facilities.

• Services available at governmental expense (except

Medicaid) whether or not the person has enrolled in

the program.

• Services for which there is no legal obligation to

pay, or for which no charge would be made if this

coverage did not exist including any service which is

normally furnished without charge.

• Services arising out of or in the course of

employment, whether or not the Covered Person

asserts his or her rights to workers’ compensation

or employers’ liability law. (This includes services

determined to be work-related but which are not

payable because of noncompliance with workers’

compensation laws or a workers’ compensation

managed care plan.)

• Charges for services provided by a person who is a

member of the Covered Person’s immediate family by

blood, marriage or adoption.

• Charges for services by a health care provider which

are not within his or her scope of practice or charges

by a person who is not an Approved Provider.

98-749 1/2024

Section 3

Limited Extension of Dental Bene ts

(Applicable to Dental Coverage Types B, C and D)

A Covered Person may be entitled to extended bene ts for

Covered Services up to 30 days after termination of coverage

under this Group Dental Plan for:

• root canal therapy, but only if the pulp chamber was

opened and the pulp canal explored to the apex

while the person was covered under this plan;

• crowns, bridges, inlays or onlay restorations, but only

if the tooth or teeth were fully prepared while the

person was covered under this plan;

• full or partial denture, but only if the master

impression was made while the person was covered

under this plan; and

• orthodontia, but only if the appliance or bands were

 rst set while the person was covered under this

plan. The amount payable will be the part of the

quarterly payment that would have been payable

had coverage remained in force during this period.

Limited Extension Ends - This extended coverage ceases on the

earlier of:

• the end of the 30-day extension period; or

• the date the person becomes eligible for such

services under another Group Dental Plan.

Please check with your employer regarding whether this

limited extension of bene ts is available to you.

98-749 1/2024

ELIGIBILITY AND ENROLLMENT

Section 4

Your employer determines eligibility requirements and

validates eligibility for enrollment and coverage under the

dental Plan. For additional information not found in this

Summary Plan Description, please contact your employer.

Who’s Eligible

To be eligible for coverage, you must apply within 31 days of

the date of hire. Coverage will be e ective on the  rst day of

the month following your date or hire or eligibility. Coverage for

Employees hired on the  rst day of the month will be e ective

on the  rst day of the month. Coverage for Employees hired on

the  rst working day of the month will be e ective on the actual

date of hire.

Retiree Eligibility

An eligible Employee who is covered under this Plan and who

retires under the employer’s formal retirement criteria will be

eligible to continue participating in the Plan upon retirement,

provided the individual continues to make the required

contribution. See the Coordination of Bene ts section for

more information on how this Plan coordinates with Medicare

coverage. Retirees may continue coverage under this Plan until

death or the last day of the month in which the Retiree ceases to

make the required premium contribution when due.

Initial Enrollment

Subscribers and dependents must enroll within 31 days of their

initial eligibility or late enrollment provisions may apply.

NOTE: If two eligible persons in the same employer group

are married to each other, each person and/or their Eligible

Dependents may not enroll under more than one membership unit.

Also, if two eligible persons have a parent/child relationship and

both are employed by the same employer Group, the parent and

child may elect to enroll either as two employees, or the parent

may enroll as an employee with dependent coverage.

Special Enrollment

A special enrollment period of 60 days is allowed for newborns

and a special enrollment period of 31 days is allowed for:

• enrollment of eligible persons due to marriage, adoption

or placement for adoption;

• enrollment of eligible persons not previously covered

under this plan due to having had other coverage at the

time it was previously o ered, and who have lost that

other coverage due to:

- exhaustion of COBRA continuation coverage; or

- a loss of eligibility, including loss due to death, divorce,

legal separation, termination of employment or

reduction in hours, or due to the plan no longer o ering

bene ts to the class of individuals that includes the

person (when the other coverage was not COBRA); or

- moving out of the service area of an HMO or other

arrangement that only provides bene ts to individuals

who reside, live or work in the service area; or

- the lifetime limit on all bene ts is exhausted; or

- the employer ceasing to make contribution for the other

coverage (when the other coverage was not COBRA).

A special enrollment period of 60 days is allowed for:

• Enrollment of eligible persons who were covered under

Medicaid or State Child Health Insurance Program (SCHIP),

which has been terminated due to loss of eligibility.

• Enrollment of eligible persons who have become eligible

for premium assistance for this group health plan coverage

under Medicaid or SCHIP.

The Subscriber must enroll (or already be enrolled ) in order

to enroll his or her dependents in this plan. In the case of a

marriage, birth or adoption, a Subscriber who is eligible, but

who has not previously enrolled, may enroll at this time with or

without the newly Eligible Dependent. Likewise an otherwise

Eligible Dependent who has not previously enrolled, may

enroll as a Special Enrollee with or without a new dependent

child. Please contact your Human Resource Department for

additional information.

Dental Late Enrollment

Employees and dependents whose dental enrollment forms are

not received within 31 days of their eligibility, are considered

“late enrollees.” A late enrollee is not eligible to apply for

dental coverage until the next Annual Enrollment Month which

follows the employee’s eligibility date, unless BCBSNE approves

a special enrollment period. A person who enrolls for coverage

during a “special enrollment period” is not considered a “late

enrollee.”

Adding A Dependent

Dependents cannot enroll unless you, the eligible employee,

are covered under the Plan. In order to add a dependent, he or

she must meet the de nition of an Eligible Dependent. Please

contact your Human Resources Department for enrollment

information and instructions.

98-749 1/2024

Section 4

E ective Date of Coverage

Provided that an appropriate membership option is in place

and, if applicable, any additional premium is paid, the e ective

date of coverage will be as follows:

Marriage: The e ective date of coverage will be the  rst of

the month following the marriage, provided the request for

enrollment is made within 31 days of the marriage.

Newborn Children: Coverage will begin at birth for your

newborn child for a period of 31 days. To continue coverage,

you must enroll the child within 60 days. If your spouse was

not enrolled at the time of the child’s birth, he or she may also

enroll within 31-days , and the e ective date will be the date of

the child’s birth.

For additional information on adding newborn children, please

contact your Human Resource Department.

Adopted Children: Coverage for an adopted child will be

e ective on the earlier of the date the child is placed with you

for adoption, or the date a court order grants custody to you.

You must enroll the child within 31 days of the placement or

custody order. If your spouse was not enrolled at the time of

the adoption, he or she may also enroll within this 31-day

period, and the e ective date of coverage will be the date of

the placement/adoption.

Loss of Other Coverage: The e ective date of coverage for

persons enrolling as a special enrollee following a loss of

other coverage will be no later than the  rst day of the month

following the loss of other coverage.

Quali ed Medical Child Support Orders (QMCSO)

A QMCSO is a court order that requires an employee to provide

medical coverage for his or her children (called alternate

recipients) in situations involving divorce, legal separation or

paternity disputes. The order may direct the Group Dental Plan

to enroll the child(ren), and also creates a right for the alternate

recipient to receive plan information, submit claims and receive

bene ts for services.

QMCSOs are speci cally de ned under the law, and are

required to include certain information in order to be

considered “quali ed.” A National Medical Support Notice

received by the employer or Group Dental Plan from a state

agency, regarding coverage for a child, will also be treated as

a QMCSO. The Plan Administrator or its designee, will review

the Order or Notice to determine whether it is quali ed, and

make a coverage determination. The Plan Administrator or

its designee will notify a ected employees and the alternate

recipient(s) if a QMCSO is received.

You have the right to request a copy of the Group Dental Plan’s

procedures governing QMCSO determinations from the Plan

Administrator, at no charge.

Active Employees Age 65 And Over

Federal law a ects the way employers provide coverage to

eligible active employees and their spouses who are 65 and

over. These active employees and their spouses ages 65 and

over may elect to continue full bene ts under the employer

group bene t plan or choose Medicare as their primary

coverage. If the group plan is elected as the primary carrier

(the plan which pays  rst), Medicare becomes the secondary

coverage. If Medicare is elected as the primary carrier, coverage

under the group plan, including dental coverage, will be

terminated.

Family Medical Leave Act (FMLA)

The Family Medical Leave Act of 1993, as amended, requires

that subject to certain limitations, most employers of 50

or more persons must o er continued coverage to eligible

employees and their covered dependents, while the employee

is on an approved FMLA leave of absence. In addition, an

employee who has terminated his/her group dental coverage

while on an approved FMLA leave is entitled to reenroll for

group dental coverage upon return to work. Please check with

your employer for details regarding your eligibility under FMLA.

98-749 1/2024

CLAIM PROCEDURES

Section 9

CLAIM PROCEDURES

Section 5

If You Receive Covered Services From An In-network

Provider

Contracting Providers and many other Dentists and Physicians

will  le the Claim to BCBSNE on your behalf. When BCBSNE

receives a Claim from a Contracting Provider, payment will

be made directly to that Provider, unless otherwise provided

by state of federal law. You are responsible for meeting any

applicable Deductible and Coinsurance amounts. You may

be asked to pay amounts that are your liability at the time of

service, or the provider may bill you for those amounts.

Filing A Claim

You must  le your own claim if your dental care provider is

not a Contracting Provider and does not  le for you. You can

obtain a claim form by contacting BCBSNE’s Member Services

Department, or you can  nd a form on the website:

NebraskaBlue.com.

All submitted claims must include:

•

correct I.D. number, including the alpha pre x;

• name of patient;

• the exact date and time of an accident (if applicable)

and whether or not it occurred at work.;

• the original, itemized dental bill, including the date

of service, description and charge for the service;

• complete name, address and credentials (DDS, MD)

of the provider;

• the name and identi cation number of other

insurance; and

• the primary plan’s explanation of bene ts (EOB), if

applicable.

Claims cannot be processed if they are incomplete, and may

be denied for “lack of information” if required information is

not received.

Claims should be  led as soon as possible after services are

provided. If a claim is not  led within the claim  ling limit

(normally within 15 months of the date of service), bene ts will

not be allowed. Claims, including revisions, that are not  led by

a BCBSNE In-network Provider prior to the claim  ling limit, will

become the provider’s liability.

Claim forms should be sent to:

Blue Cross and Blue Shield of Nebraska

P.O. Box 3248

Omaha, Nebraska 68180-0001

If you need assistance with  ling your claim, please contact

BCBSNE’s Member Services Department.

Payment Of Bene ts For Non-Contracting Provider

Claims

Payment will be made, at BCBSNE’s option, to the Covered

Person, to his or her estate, to the provider or as required by

state or federal law. Bene ts may also be paid to an alternate

recipient or custodial parent, if pursuant to a QMCSO.

No assignment, whether made before or after Services are

provided, of any amount payable according to this group

bene t plan shall be recognized or accepted as binding upon

BCBSNE, unless otherwise provided by state or federal law.

Right to Amend Provider Agreements Or Bene t

Payment Procedures

Agreements with health or dental care providers may be

changed or terminated, and bene t payments to In-network

Providers may be altered. Bene t payments may be calculated

on a charge basis, a Contracted Amount or similar charge,

global fee basis, through a Preferred Provider Organization, or

in any other manner agreed upon by BCBSNE or the On-site

Plan and the provider. However, any payment method agreed

upon will not a ect the method of calculating the Deductible

and Coinsurance.

Claim Determinations

A “Claim” may be classi ed as a “Preservice” or “Postservice”.

Preservice Claims — In some cases, under the terms of

the Group Dental Plan, the Covered Person is required to

Preauthorize bene ts in advance of a Service being provided,

or bene ts for the Service may be reduced or denied. This

required request for a bene t is a “Preservice” Claim.” Preservice

Claim determinations that are not Urgent Care Claims will be

made with 15 calendar days of receipt, unless an extension

is needed to obtain necessary information. If additional

information is requested, the Covered Person or his or her

provider may be given up to 45 calendar days from receipt

of notice to submit the speci ed information. A Claim

determination will be made within 15 days of receipt of the

information, or the end of the 45 day extension period.

Urgent Care — If your Preservice Claim is one for Urgent Care,

the determination will be made within 72 hours of receipt of

the claim, unless further information is needed. If additional

information is necessary, the Covered Person or his or her

provider will be given no less than 48 hours to provide the

speci ed information. Noti cation of the decision will be

provided not later than 48 hours after the earlier of: our receipt

of the information, or the end of the period allowed to submit

the information.

98-749 1/2024

Section 5

Postservice Claims — A Postservice Claim is any Claim that

is not a Preservice Claim. In most cases, a Postservice Claim

is a request for bene ts or reimbursement of expenses for

medical care that has been provided to a Covered Person.

The instructions for  ling a Postservice Claim are outlined

earlier in this section. Upon receipt of a completed claim form,

a Postservice Claim will be processed within 30 days, unless

additional information is needed. If additional information

is requested, the Covered Person may be given not less

than 45 days to submit the necessary information. A Claim

determination will be made within 15 days of receipt of the

information, or the expiration of the 45-day extension period.

You will receive an EOB when a Claim is processed which

explains the manner in which your claim was handled.

Concurrent Care — If you request to extend a course of

treatment beyond the care previously approved and it involves

urgent care, a decision will be made within 24 hours of the

request, if you submitted the request at least 24 hours before

the course of treatment expires. In all other cases, the request

for an extension will be decided as appropriate for a Preservice

and Postservice Claims.

Explanation Of Bene ts

Every time a claim is processed for you, an Explanation of

Bene ts (EOB) form will be sent. The front page of the EOB

provides you with a summary of the payment including:

• the patient’s name and the claim number.

• the name of the individual or institution that was

paid for the service.

• the total charge associated with the claim.

• the covered amount.

• any amount previously processed by this plan,

or another insurance company.

• the amount(s) that you are responsible to pay

the Provider.

• the total Deductible, Coinsurance that you have

accumulated to date.

• other general messages.

A more detailed breakdown of the charges including provider

discounts, amount paid and cost sharing amounts (e.g.

noncovered charges, Deductible, Coinsurance and Copays)

are shown on the back of your EOB.

Also included on your EOB is information regarding your

right to appeal a bene t determination, or request additional

information.

Save your EOBs in the event that you need them for other

insurance or for tax purposes.

98-749 1/2024

APPEAL PROCEDURES

Section 6

BCBSNE has the discretionary authority to determine eligibility

for bene ts under the dental Plan, and to construe and

interpret the terms of the Plan, consistent with the terms of

the Administrative Services Agreement and associated plan

document.

You have the right to seek and obtain a review of “adverse

bene t determinations” arising under the Plan.

Appeal Procedure De nitions

Adverse Bene t Determination: A determination by BCBSNE

or its Utilization Review designee, of the denial, reduction,

or termination of a bene t, or a failure to provide or make

payment (in whole or in part) of a bene t. This includes any

such determination that is based on:

• the application of Utilization Review;

• a determination that the Service is Investigative;

• a determination that the Service is not Medically

Necessary or appropriate;

• an individual’s eligibility for coverage or to

participate in a plan.

An Adverse Bene t Determination also includes any

rescission of coverage, which is de ned as a cancellation or

discontinuance of coverage that has a retroactive e ect, except

if for failure to timely pay required premiums or contribution

for coverage.

Final Internal Adverse Bene t Determination: An Adverse

Bene t Determination that has been upheld by BCBSNE, or its

Utilization Review designee, at the completion of the internal

appeal process as described in this document.

Preservice Claim(s): Any Claim for a bene t under the Plan

with respect to which the terms of the Contract require

approval of the bene t in advance of obtaining medical care,

and failure to do so will cause bene ts to be denied or reduced.

Postservice Claim(s): Any Claim that is not a Preservice Claim.

Urgent Care Claim: A Claim for medical care or treatment for

which the application of the time periods for making non-

urgent care determinations:

• could seriously jeopardize the life or health of the

Covered Person or the ability of the Covered Person

to regain maximum function; or

• would subject the Covered Person to severe pain that

cannot be adequately managed without the care or

treatment that is the subject of the Claim.

How To Appeal An Adverse Bene t Determination

A Covered Person or a person acting on his/her behalf (the

“claimant”) is entitled to an opportunity to appeal initial or  nal

Adverse Bene t Determinations.

Internal Appeal

A request for an internal appeal must be submitted within

6 months of the date the Claim was processed, or Adverse

Bene t Determination was made. The written request should

state that it is a request for an appeal and, if possible, include a

copy of the Explanation of Bene ts (EOB). The appeal should

also include:

• the name of the person submitting the appeal and

his/her relationship to the patient;

• the reason for the appeal;

• any information that might help resolve the issue; and

• the date of service/Claim.

The written appeal should be sent to:

Blue Cross and Blue Shield of Nebraska

P.O. Box 3248

Omaha, Nebraska 68180-0001

BCBSNE will provide the claimant a notice of receipt of the

request within 3 days. The notice will include the name,

address and telephone number of a person to contact

regarding coordination of the review. The claimant does not

have the right to attend the appeal review, but may submit

additional information or comments for consideration.

Preservice or Postservice Claim Appeal: A written notice

of the appeal determination will be provided to the claimant

as follows:

• for Preservice Claims (other than Urgent Care), within

15 calendar days after receipt.

• for Postservice Claims involving an Adverse Bene t

Determination based on Medical Necessity,

Investigative determination or utilization review,

within 15 calendar days after receipt.

• for all other Postservice Claims, within 15 calendar

days after receipt, unless additional time is needed

and written notice is provided on or before the 15th

day, in which case the decision will be provided

within 30 calendar days after receipt.

The decision made pursuant to this appeal will be considered a

Final Internal Adverse Bene t Determination.

98-749 1/2024

Section 6

Nebraska Department of Insurance Assistance

The Nebraska Department of Insurance may be contacted for

assistance with the formal appeal process at any time at:

Nebraska Department of Insurance

P.O. Box 82089

Lincoln, Nebraska 68501-2089

(877) 564-7323

If you have a general complaint or inquiry regarding your

coverage with BCBSNE, please contact the Member Services

Department at the number found on your ID card. If you feel

that your complaint is not resolved through BCBSNE’s inter-

nal complaint process, or if performance does not meet your

expectations, you may contact the Nebraska Department of

Insurance at the address and phone number above.

Expedited Appeal: When the appeal is related to an Urgent

Care Claim, an expedited appeal may be requested in writing or

orally. All information, including the decision, will be submitted

by the most expeditious method available. BCBSNE will make

an expedited review decision within 72 hours after the appeal

is received. Written noti cation of the decision will be sent

within the 72-hour period.

Concurrent Care denials must be appealed within 24 hours

of the denial. A Concurrent Care denial will be handled as an

expedited appeal. If the appeal is requested within the 24-

hour time period, coverage will continue for services pending

noti cation of the review decision.

NOTE: When an adverse appeal determination involves

medical judgment, upon receipt of a written request, the

identity of the professionals who reviewed the appeal will be

provided to the claimant.

Rights To Documentation

You have the right to have access to, and request copies of

the documentation relevant to the claim and Adverse Bene t

Determination(s), including any new evidence or rationale

considered or relied upon in connection with the claim

on review. In addition, supporting material or additional

comments may be submitted by the claimant for consideration

during the appeal process.

98-749 1/2024

COORDINATION OF BENEFITS

Section 7

When You Have Coverage Under More Than One

Plan

This Plan includes a Coordination of Bene ts (COB) provision.

COB provisions apply when a Covered Person has coverage

under more than one health Plan. This provision establishes

a uniform order in which the Plans pay their Claims, limits the

duplication of bene ts, and provides for transfer of information

between the Plans.

The order of bene t determination rules described in this

section determine which Plan will pay as the primary Plan

without regard to any bene ts that might be payable by

another Plan.

De nitions

For the purpose of this section, the terms are de ned as:

Allowable Expense: A health care expense, including

deductibles, coinsurance and copayments, that is covered at

least in part by any Plan covering the person. When a Plan

provides bene ts in the form of services, the reasonable cash

value of each service will be considered an Allowable Expense

and a bene t paid. An expense that is not covered by any Plan

covering the person is not an Allowable Expense. In addition,

any expense that a provider by law or in accordance with a

contractual agreement is prohibited from charging a Covered

Person is not an Allowable Expense.

The amount of any bene t reduction by the Primary Plan

because a Covered Person has failed to comply with the Plan

provisions is not an Allowable Expense. Examples of these

types of Plan provisions include second surgical options,

pre authorization of admissions, and preferred provider

arrangements.

Closed Panel Plan: A Plan that provides health care bene ts

to covered persons primarily in the form of services through a

panel of providers that have contracted with or are employed

by the Plan, and that excludes coverage for services provided

by other providers, except in cases of emergency or referral by

a panel member.

Custodial Parent: The parent awarded custody by a court

decree or, in the absence of a court decree, the parent with

whom the child resides more than one half of the calendar year

excluding temporary visitation.

Plan: As used in this section, any of the following that

provides bene ts or services for medical or dental care

or treatment. If separate contracts are used to provide

coordinated coverage for members of a group, the separate

contracts are considered parts of the same Plan and there is no

COB among those separate contracts.

a. Plan includes: group and nongroup insurance

contracts and subscriber contracts, health maintenance

organization (HMO) contracts, Closed Panel Plans;

other forms of group or group-type coverage (whether

insured or uninsured); medical care components of

long-term care contracts, such as skilled nursing care;

medical bene ts coverage in automobile “no-fault” and

traditional “fault” type contracts; group and nongroup

insurance contracts and subscriber contracts that pay

or reimburse for the cost of dental care; and Medicare

or any other federal governmental Plan, as permitted by

law.

b. Plan does not include: hospital indemnity coverage or

other  xed indemnity coverage; accident only coverage

other than the medical bene ts coverage in automobile

“no fault” and traditional “fault” contracts; speci ed

disease or speci ed accident coverage; limited bene t

health coverage, as de ned in state law; school accident

coverage; bene ts for non-medical components of

long-term care policies; Medicare supplement policies;

Medicaid policies; and coverage under other federal

governmental Plans, unless permitted by law.

Each contract for coverage under a. or b. is a separate Plan. If a

Plan has two parts and COB rules apply only to one of the two,

each of the parts is treated as a separate Plan.

Primary Plan: The Plan that will determine payment for

its bene ts  rst before those of any other Plan without

considering any other Plan’s bene ts.

Secondary Plan: The Plan that will determine its bene ts after

those of another Plan and may reduce the bene ts so that

all Plan bene ts do not exceed 100% of the total Allowable

Expense.

This Plan: The part of the contract providing health care

bene ts to which the COB provision applies and which may

be reduced because of the bene ts of other Plans. A contract

may apply one COB provision to certain bene ts, such as dental

bene ts, coordinating only with similar bene ts, and may apply

another COB provision to coordinate other bene ts.

98-749 1/2024

Section 7

Order Of Bene t Determination Rules

1. The Primary Plan pays or provides its bene ts according

to its terms or coverage and without regard to the

bene ts under any other Plan.

2. A Plan that does not contain a coordination of bene ts

provision that is consistent with this Part is always

primary unless the provisions of both Plans stated that

the complying Plan is primary.

3. A Plan may consider the bene ts paid or provided by

another Plan in calculating payment of its bene ts only

when it is secondary to that other Plan.

4. Each Plan determines its order of bene ts using the  rst

of the following rules that apply:

Subscriber And Dependent: The Plan that covers the person

as other than a dependent, such as a subscriber/policyholder/

employee is the Primary Plan and the Plan that covers the

person as a dependent is the Secondary Plan. However, if the

person is a Medicare bene ciary and, as a result of federal law,

Medicare is secondary to the Plan covering the person as a

dependent and primary to the Plan covering the person as a

subscriber, then the order of bene ts between the two Plans is

reversed so that the Plan covering the person as a subscriber is

the Secondary Plan and the other Plan is the Primary Plan.

Dependent Child Covered Under More Than One Plan:

Unless there is a court decree stating otherwise, when a

dependent child is covered by more than one Plan the order of

bene ts is determined as follows:

For a dependent child whose parents are married or are living

together, whether or not they have ever been married, the Plan

of the parent whose birthday falls earlier in the calendar year is

the Primary Plan. If both parents have the same birthday, the

Plan that has covered the parents the longest is the Primary

Plan (birthday rule).

For a dependent child whose parents are divorced, separated

or not living together, whether or not they have ever been

married, if a court decree states that one of the parents is

responsible for the child’s health care expenses or health care

coverage and the Plan of that parent has actual knowledge

of those terms, that Plan is primary. If the parent with

responsibility has no health care coverage for the dependent

child’s health care expenses, but that parent’s spouse does,

the Plan of that parent’s spouse is primary. This rule applies to

Plan years beginning after the Plan is given notice of the court

decree.

If a court decree states that both parents are responsible for

the dependent child’s health care expenses or health care

coverage, the order of bene ts shall be determined by the

“birthday rule” stated above.

If a court decree states that the parents have joint custody

without specifying that one parent has responsibility for the

health care expenses or health care coverage of the dependent

child, the order of bene ts shall be determined by the “birthday

rule” stated above.

If there is no court decree allocating responsibility for the

dependent child’s health care expenses or health care

coverage, the order of bene ts for the child are as follows:

• the Plan covering the Custodial Parent;

• the Plan covering the spouse of the Custodial Parent;

• the Plan covering the non-custodial parent; and then

• the Plan covering the spouse of the non-custodial parent.

For a dependent child covered under more than one Plan

of individuals who are not parents of the child, the above

provisions shall apply as if those individuals were the parents.

For an Eligible Dependent child covered under either or

both parents’ plans and also has his or her own coverage as a

dependent under a spouse’s plan, the rule below for “Longer or

Shorter Length of Coverage” applies. In the event the Eligible

Dependent child’s coverage under the spouse’s plan began on

the same date as his or her coverage under the parents’ plan(s),

the order of bene ts shall be determined by applying the

“birthday rule” above, to the child’s parent(s) and to his or her

spouse.

Active Employee, Retired Or Laid-O Employee: The Plan that

covers a person as an active employee, that is, an employee

who is neither retired nor laid o , is the Primary Plan. The Plan

covering that same person as a retired or laid-o employee is

the Secondary Plan. The same would hold true if a person is a

dependent of an active employee and that same person is a de-

pendent of a retired or laid-o employee. If the other Plan does

not have this rule, and as a result, the Plans do not agree on the

order of bene ts, this rule is ignored. This rule does not apply

if the  rst rule (Subscriber and Dependent) can determine the

order of bene ts.

98-749 1/2024

paid or provided by all Plans for the Claim do not exceed

the total Allowable Expense for that Claim. In addition, the

Secondary Plan shall credit to its Plan Deductible any amounts

it would have credited to its Deductible in the absence of other

health coverage.

Miscellaneous Provisions

If these COB rules do not speci cally address a particular

situation, BCBSNE may, at its discretion, rely on the National

Association of Insurance Commissioners Coordination of

Bene ts Model Regulation as an interpretive guide.

To properly administer these COB rules, certain facts are

needed. This Plan may obtain or release information to any

insurance company, organization or person. Any person

who claims bene ts under This Plan agrees to furnish the

information that may be necessary to apply COB rules and

determine bene ts.

If another Plan pays bene ts that should have been paid under

This Plan, this Plan may reimburse the other Plan amounts

determined to be necessary. Amounts paid to other Plans in

this manner will be considered bene ts paid under This Plan

and This Plan is released from liability for any such amounts.

If the amount of the bene ts paid by This Plan exceeds the

amount it should have paid, This Plan has the right to recover

any excess from any other insurer, any other organization, or

any person to or for whom such amounts were paid, including

Covered Persons under This Plan.

COBRA Or State Continuation Coverage: If a person whose

coverage is provided pursuant to COBRA or under a right of

continuation provided by state or other federal law is covered

under another Plan, the Plan covering the person as a sub-

scriber/member/employee/retiree or covering the person as a

dependent of a subscriber/member/employee/retiree is the Pri-

mary Plan and the COBRA or state or other federal continuation

coverage is the Secondary Plan. If the other Plan does not have

this rule, and as a result, the Plans do not agree on the order of

bene ts, this rule is ignored. This rule does not apply if the  rst

rule (Subscriber and Dependent) can determine the order of

bene ts.

Longer Or Shorter Length Of Coverage: The Plan that has cov-

ered the person longer is the Primary Plan and the Plan that has

covered the person the shorter period of time is the Secondary

Plan. The start of a new Plan does not include a change in the

amount or scope of a Plan’s bene ts; a change in the entity that

pays, provides or administers the Plan’s bene ts; or a change

from one type of Plan to another, such as from a single employ-

er Plan to a multiple employer Plan.

If the above rules do not determine the order of bene ts, the

Allowable Expenses shall be shared equally between the Plans

meeting the de nition of Plan. In addition, This Plan will not

pay more than it would have paid had it been the Primary Plan.

Administration Of Coordination Of Bene ts

The order of bene t determination rules govern the order in

which each Plan will pay a Claim for bene ts. The Plan that

pays  rst is called the Primary Plan. The Plan that pays after the

Primary Plan is called the Secondary Plan.

If This Plan is the Primary Plan, there shall be no reduction of

bene ts. Bene ts will be paid without regard to the bene ts of

any other Plan.

If This Plan is the Secondary Plan, it may reduce its bene ts

so that the total bene ts paid or provided by all Plans for

any Claim are not more than the total Allowable Expenses.

In determining the amount to be paid for any Claim, the

Secondary Plan will calculate the bene ts it would have paid

in the absence of other health care coverage and apply that

calculated amount to any Allowable Expense under its Plan that

is unpaid by the Primary Plan. The Secondary Plan may then

reduce its payment by the amount so that, when combined

with the amount paid by the Primary Plan, the total bene ts

Section 7

98-749 1/2024

WHEN COVERAGE ENDS

Section 8

Termination of Coverage

Coverage under your group plan will terminate for you and/or

your dependents on the earliest of the following dates:

• the date the entire Contract is terminated;

• the last day of the month in which your employment

terminates;

• the last day of the month in which you cease to be eli-

gible under the health plan; or a dependent ceases to be

an Eligible Dependent;

• the last day of the month in which BCBSNE receives a re-

quest from you or the employer to terminate coverage for

you or a dependent, or the date requested in the notice,

if later;

• the last date for which premium is paid;

• another date as speci ed by your employer;

NOTE: If an employee voluntarily cancels his/her dental coverage,

the employee and his/her eligible dependents may not re-enroll for

two years from the  rst month following the date of cancelation.

You and/or your Eligible Dependents may be eligible to

continue coverage under the Group Dental Plan as detailed in

this section.

Leave of Absence

If You are temporarily absent from work due to an approved

leave of absence for medical or other reasons. Your coverage

under this Plan will continue during that leave for up to two

years, provided the applicable Employee contribution is paid

when due.

Continuation Of Coverage Under The Federal

Continuation Law

If you terminate your employment, or if a dependent loses

coverage due to certain “Qualifying Events”, continued coverage

under the Group Dental Plan may be available. Payment for

continued coverage under the federal continuation law is at the

employee’s or dependent’s own expense. Please contact your

employer for details regarding eligibility.

What Is The Federal Continuation Law?

The Consolidated Omnibus Reconciliation Act (COBRA), is

a federal law which provides that a Covered Person who

would lose coverage due to the occurrence of a “Qualifying

Event”, may elect to continue coverage under the Group

Dental Plan. A person who is eligible to continue coverage

is called a “Quali ed Bene ciary.” A Quali ed Bene ciary

also includes a child born to, or placed for adoption with the

Covered Person during the period of COBRA coverage. Please

share the information found in this section with your Eligible

Dependents.

NOTE: To protect your rights under COBRA, please keep your

employer informed of your current address.

Termination Of Employment Or Reduction In Hours – COBRA

provides that if you should lose eligibility for coverage due to:

• voluntary or involuntary termination of employment

(other than for gross misconduct) ;

• a lay-o for economic reasons; or

• a reduction in work hours

you and your covered dependents may be able to continue the

group coverage at your own expense for up to 18 months. Your

employer is required to notify the Plan Administrator within 30

days of the loss of coverage. The Plan Administrator will send

the Quali ed Bene ciaries a COBRA noti cation within 14 days

after receiving notice from the employer. If the employer and

Plan Administrator are the same entity, the COBRA noti cation

will be sent within 44 days of the date of the loss of coverage.

Disability – If a Quali ed Bene ciary is determined by the

Social Security Administration to have been disabled any

time during the  rst 60 days of COBRA continuation coverage,

the COBRA coverage period for the disabled individual

and his or her related bene ciaries may be extended to 29

months instead of 18 months when loss of coverage is due

to termination or reduction in hours of employment. You

must provide written notice of the disability determination to

the plan within 18 months of becoming eligible for COBRA

and no later than 60 days after the date of the Social Security

Administration’s determination.

If the Social Security Administration determines that you or the

dependent are no longer disabled, the extended continuation

of coverage period (19th through 29th month) will be

terminated the month that begins more than 30 days after the

determination. You must notify the plan within 30 days of a

determination that an individual is no longer disabled.

Change In Dependent Status, Divorce/Separation Or

Medicare Entitlement – COBRA requires that continued

coverage under the Plan be o ered to your covered spouse

and eligible children if they would otherwise lose coverage as a

result of:

• divorce or legal separation;

• a child losing dependent status, or

• the employee becoming entitled to Medicare.

When one of these circumstances occur, you or the dependent

are obligated to notify the employer or Plan Administrator

within 60 days. Failure to provide timely and proper notice may

result in the loss of the right to COBRA.

98-749 1/2024

Section 12Section 8

dependents of the monthly premium amount, and to whom

such premium should be paid.

Second Qualifying Event — In the event your family

experiences a second Qualifying Event while receiving an

18-month period of COBRA coverage (or the extended

29-month period), your covered spouse and dependents

are eligible to extend the original COBRA coverage period

to a maximum of 36 months if notice of the second event is

properly given to the Plan Administrator. This extension may

be available to the spouse and children receiving continuation

coverage if: a) you die, b) you become entitled to Medicare, c)

you get divorced or legally separated, or d) the dependent child

is no longer eligible as a dependent, but only if the second

event would have caused the spouse or child to lose coverage

under the plan had the  rst Qualifying Event not occurred.

In all of these cases, you or the dependent must notify the

Plan Administrator, in writing, within 60 days of the second

Qualifying Event. Failure to provide timely and proper notice

may result in the loss of the right to extend COBRA coverage.

Termination Of COBRA Coverage

A Quali ed Bene ciary’s COBRA continuation coverage may be

terminated at midnight on the earliest of:

• the day your employer ceases to provide any Group

Dental Plan to any employee;

• the day the premium is due and unpaid;

• the day the individual  rst becomes covered under any

other Group Dental Plan (after the COBRA election);

• the day the individual again becomes covered as an

employee or dependent under the policy;

• the day an insured person becomes entitled to bene ts

under Medicare (after COBRA election); or

• the day dental insurance has been continued for the

maximum period of time allowed (18, 29 or 36 months).

NOTE: In the event more than one continuous provision applies,

the periods of continued coverage may run concurrently, but never

for more than 36 months.

Uniformed Service Employment And Reemployment

Rights (Military Leave)

The Uniformed Services employment and Reemployment

Rights Act of 1994 (USERRA) requires that continued coverage

under an employer group plan be o ered to an employee and

covered dependents if coverage would otherwise be lost due

to military leave.

After receiving a timely notice of such an event, your employer

or the Plan Administrator will send the Quali ed Bene ciary

an election form and the information needed to apply for

coverage, if eligible, within 14 days of the date the notice

is received. Coverage may be continued at the individual’s

expense for up to 36 months.

Your Death – If you should die while you are covered under

this Group Dental Plan, continued coverage is available to your

spouse and Eligible Dependents.

COBRA provides that subject to certain limitations, your

surviving spouse and children may continue the group dental

coverage at their own expense for up to 36 months. Federal

law requires your Plan Administrator to send the surviving

family members instructions as to how to apply for continued

coverage if they are eligible.

Special Provisions — If an employer  les Chapter 11

bankruptcy, special provisions regarding COBRA continuation

coverage may apply for a retiree or deceased retiree’s surviving

spouse and dependent children. Please check with your

employer for details.

Electing COBRA Coverage

Quali ed Bene ciaries will be sent a written notice of the right

to continue health coverage and an election form(s).

Reminder: In the case of a divorce or legal separation, or if a child

loses dependent status, you must notify your employer or plan

administrator of this Qualifying Event within 60 days. Failure to

provide timely and proper notice may result in the loss of the right

to COBRA coverage.

Quali ed Bene ciaries must complete and return the COBRA

election form in order to continue coverage. The notice will

include instructions for completing and returning the form.

The election form must be received by the later of:

• 60 days after the day health coverage would

otherwise end, or

• 60 days after the notice is sent to you by the

employer or Plan Administrator.

COBRA continuation coverage may only begin on the day after

coverage under the group plan would otherwise end. The

required premium, including any retroactive premium, must

be paid from the day coverage would have otherwise ended.

The initial premium must be paid within 45 days after the day

continued coverage is elected. Succeeding premiums must

be paid monthly within 30 days of the premium due date.

The COBRA notice and election form will inform you or your

98-749 1/2024

Section 8

Continuation of Group Health Coverage

If coverage under your employer group plan ends because of

service in the uniformed services, you may elect to continue

coverage yourself and your covered dependents, until the

earlier of:

• 24 consecutive months from the date active duty began;

• the day after the date on which you fail to apply for, or

return to employment, in accordance with USERRA.

You are responsible for payment of the required premium to

continue coverage. If the leave for military service is less than

31 days, your required premium is the standard employee

share of the applicable premium . For a leave in excess of 30

days the required premium shall be no more than 102% of the

total premium applicable for your membership option. Your

employer will inform you of the amount and procedure for

payment of premiums.

A Covered Person’s continued coverage under these USERRA

provisions will end at midnight on the earliest of:

• the day the employer ceases to provide any group plan

for its employee,

• the day the premium is due and unpaid,

• the day a Covered Person again becomes covered under

the plan,

• the day coverage has been continued for the period of

time stated in the previous paragraph above.

Reemployment

Following service in the uniformed services, an employee may

be eligible to apply for reemployment with the employer in

accordance with USERRA. Such reemployment includes the

right to reenroll for group coverage provided by the employer

with no new waiting periods imposed.

Please contact your Human Resource Department for further

information with regard to your rights under USERRA.

Continuation Of Coverage For Children To Age 30

You may elect to continue coverage to age 30 for a dependent

who would otherwise lose coverage when he or she meets

the plan’s limiting age provided that the child was covered as

an Eligible Dependent at the time such coverage would have

terminated.

In order to elect continuation coverage, you must request

an election form from BCBSNE. The completed form must be

returned no sooner than 31 days prior to or no later than 31

days after the date on which the child would otherwise lose

coverage. You should also notify your employer of your decision

to continue coverage for your child.

Payment For Continuation Coverage

The premium for continuation coverage will be equal to the

full, unsubsidized single adult premium. You are responsible for

paying the full premium each month. The  rst month’s premium

must be paid to the Group through which your coverage is

provided no later than 31 days after the date the child’s coverage

would have terminated.

Termination of Continuation Coverage

Continuation coverage will terminate if:

•

we do not receive the monthly payment on a timely basis;

•

you request coverage to be terminated;

•

your coverage with Blue Cross and Blue Shield of Nebraska

terminates;

•

the covered child:

—

marries;

—

is no longer a resident of Nebraska;

—

receives coverage under another health bene t plan or

self-funded employee bene t plan; or

—

attains age 30.

Continuation coverage will terminate at the end of the month

in which any event listed above occurs. Coverage may not be

reinstated once it has been terminated.

98-749 1/2024

GENERAL LEGAL PROVISIONS

Section 13

GENERAL LEGAL PROVISIONS

Section 9

Bene t Plan Document

This document provides an overview of your bene ts. It is

not intended to be a complete description of every detail

of the Plan. All coverage and bene t determinations are

governed by the Bene t Plan Document, which consists of

the Administrative Services Agreement, this SPD, and other

documents entered into between the Group and BCBSNE.

Fraud Or Misrepresentation

A Covered Person’s coverage may be canceled or rescinded for

fraud or intentional misrepresentation of a material fact about

a claim or eligibility for this coverage.

If coverage is rescinded, the amount of premium paid will be

reduced by any bene ts that were paid, and will be refunded.

If bene ts paid exceed premiums, received, BCBSNE may

recover the di erence.

Contracting Providers

BCBSNE does not engage in the practice of medicine and all

Contracting Providers provide Services under the terms of the

Plan as independent practitioners of the healing arts. Such

providers are not employees or agents of BCBSNE, or the On-

site Plan, and BCBSNE will not be liable for any act, error, or

neglect of any Hospital, Physician, Dentist or other provider or

their agent, employee, successor or assignee.

Subrogation

Subrogation is the right to recover bene ts paid for Covered

Services provided as the result of Injury or Illness which was

caused by another person or organization. When bene ts are

paid under the Group Plan, the Plan shall be subrogated to all

of the Covered Person’s right of recovery against any person or

organization to the extent of the bene ts paid. The Subscriber,

the Covered Person or the person who has the right to recover

for a Covered Person (usually a parent or spouse), agrees

to make reimbursement to the Plan if payment is received

from the person who caused the Illness or Injury or from that

person’s liability carrier.

This subrogation shall be a  rst priority lien on the full or partial

proceeds of any settlement, judgement or other payment

recovered by or on behalf of the Covered Person, whether or

not there has been full compensation for all his or her losses or

as provided by applicable state law. The Plan’s rights shall not

be defeated by allocating the proceeds in whole or in part to

nonmedical damages.

Contractual Right To Reimbursement

If a Covered Person receives full or partial proceeds from any

other source for Covered Services for an Illness or Injury, the

Group Plan has a contractual right of reimbursement to the

extent bene ts were paid under the Plan for the same Illness

or Injury. This contractual right to reimbursement shall be

a  rst priority lien against any proceeds recovered by the

Covered Person, whether or not the Covered Person has been

fully compensated for all his or her losses, or as provided by

applicable state law.

Such proceeds may include any settlement; judgment;

payments made under group auto insurance; individual or

group no fault auto insurance; another person’s uninsured,

under insured or medical payment insurance; or proceeds

otherwise paid by a third party. This contractual right to

reimbursement is in addition to and separate from the

subrogation right. The Plan’s rights shall not be defeated by

allocating the proceeds in whole or in part, to nonmedical

damages.

When proceeds are recovered under this contractual right

to reimbursement for all or a part of the Claim, amounts

previously credited to a Covered Person’s Deductible or

Coinsurance liability may be removed. Future Claims will be

subject to the reinstated Deductible or Coinsurance.

No adult Subscriber may assign any rights to recover

medical expenses from any third party to any minor or other

dependent of the adult Subscriber or to any other person,

without the express written consent of the Plan. The right

to recover, whether by subrogation or reimbursement, shall

apply to settlements or recoveries of deceased persons,

minor dependents of a Subscriber, incompetent or disabled

Subscribers, or their incompetent or disabled Eligible

Dependents.

The Subscriber agrees to fully cooperate and assist in any way

necessary to recover such payments, including but not limited

to notifying BCBSNE of a claim or lawsuit  led on his or her

behalf or on behalf of any Eligible Dependent for an Injury or

Illness. The Subscriber, Eligible Dependent or an authorized

representative shall contact BCBSNE prior to settling any claim

or lawsuit to obtain an updated itemization of the subrogation

Claim or reimbursement amount due. Upon receiving any

proceeds, the Subscriber, Eligible Dependent or an authorized

representative must hold such proceeds in trust until such

time as the proceeds can be transferred to the Plan. The party

holding the funds that rightfully belong to the Plan shall not

interrupt or prejudice its recovery of such payments.

98-749 1/2024

Section 9

Costs incurred in enforcing these provisions shall also be

recovered, including, but not limited to, attorneys’ fees,

litigation and court costs and other expenses.

Workers’ Compensation

Bene ts are not available for Services provided for Injuries

or Illnesses arising out of and in the course of employment

whether or not the Covered Person fails to assert or waives his

or her right to Workers’ Compensation or Employer Liability

Law. The employer is required to furnish or pay for such

Services or a settlement can be made, pursuant to Workers’

Compensation laws. (See also the section of this book titled

“Exclusions — What’s Not Covered”)

If a Covered Person enters into a lump-sum settlement which

include compensation for past or future dental expenses for

an Injury or Illness, payment will not be made under the Group

Dental Plan for Services related to that Injury or Illness.

Bene ts are not payable for services determined to be not

compensable due to noncompliance with terms, rules and

conditions under Workers’ Compensation laws, or in a Certi ed

or otherwise Licensed Workers’ Compensation Managed Care

Plan. In addition, bene ts are not payable for Services that

are related to the work Injury or Illness, but are determined to

be not necessary or reasonable by the employer or Workers’

Compensation carrier.

In certain instances, bene ts for such Services are paid in error

under the group plan. If payment is received by the Covered

Person for such Services, reimbursement must be made. This

reimbursement may be refunded from any recovery made from

the employer, or the employer’s Workers’ Compensation carrier,

as permitted by law. Reimbursement must be made directly

by the Subscriber when bene ts are paid in error due to his or

her failure to comply with the terms, rules and conditions of

Workers’ Compensation laws or a Certi ed or Licensed Workers’

Compensation Managed Care Plan.

Legal Actions

The Subscriber cannot bring legal action to recover for at least

60 days after written proof of loss is given to BCBSNE. The

Subscriber cannot start a legal action after three years from the

date written proof of loss is required.

98-749 1/2024

DEFINITIONS

Section 10

Accident: An unexpected occurrence that results in injury, loss

or damage such as a fall or auto accident. Fractures of teeth

due to eating, biting or chewing are not considered Accidents.

Administrative Services Agreement (ASA): The agreement

entered into between the Group and BCBSNE for

administration of the Group’s self-insured, or partially self-

insured, health care programs for eligible employees.

Adult Designee: A person of the same or opposite gender

of the Subscriber, who meets the eligibility criteria below, as

determined by the University of Nebraska:

•

has resided in the same residence as the Subscriber for

at least the past 12 months and intends to remain so

inde nitely;

•

is at least 19 years old;

•

is directly dependent upon, or interdependent with, the

employee, sharing a common  nancial obligation that can

be documented in a manner prescribed by the University

of Nebraska;

•

is not currently married to or legally separated from

another individual either under statutory or common law;

•

is not related to the Subscriber as a parent, step-parent, a

collateral descendent of a parent or step-parent (i.e. sibling,

niece or nephew), a grandparent, step-grandparent, or a

grandparent’s or step-grandparent’s descendant (i.e. aunt,

uncle or cousin);

•

is not a renter, boarder, tenant or employee of the

Subscriber;

•

has not been hired or is not directly supervised by the

Subscriber in an employment settling; or may not be

transferred, suspended, laid o , recalled, promoted,

discharged, assigned, rewarded or disciplined as an

employee by the Subscriber; or the Subscriber has no

responsibility to direct the Adult Designee or to adjust the

Adult Designee’s grievances or e ectively to recommend

such action, if the exercise of such authority is not merely

of a routine or clerical nature but requires the use of

independent judgment;

•

is not a child of the Subscriber or a descendent of a

Subscriber’s child.

In addition, the Subscriber and the Adult designee must possess

and provide the University of Nebraska either a copy of the

Internal Revenue Services (IRS) form listing the Adult Designee

as a dependent, or at least three of the following documents;

•

joint ownership of a residence or other signi cant property

(home, condo, mobile home, care) or joint tenancy on a

resident lease identifying both the Subscriber and the

Adult Designee as tenants;

•

life insurance policy or retirement bene t account of the

Subscriber or the Adult Designee naming the other as

primary bene ciary;

•

will of the Subscriber or Adult Designee designating

the other as primary bene ciary, executor or personal

representative;

•

durable power of attorney for purposes of health care or

 nancial management providing that the Subscriber and

Adult Designee have granted powers to one another;

•

joint bank or credit account;

•

joint liability of debt (for example, credit cards or car loans);

•

other evidence of joint ownership of a major asset.

If there is any change in status regarding the Adult Designee

of the Adult Designee’s dependent children, the Subscriber

is responsible for notifying the University of Nebraska within

31 days of the change. Coverage will be terminated for the

Adult Designee and his/her dependent children when an

Adult Designee no longer meets the eligibility criteria listed

above. Unless otherwise stated, an Adult Designee and his/her

dependent children will not be o ered an independent right to

continuation of bene ts through COBRA if these individuals lose

coverage under this Plan for any reason; although the Subscriber

may elect to continue coverage through COBRA for the

Subscriber, the Adult Designee and his/her dependent children

if the Subscriber becomes eligible for COBRA continuation

coverage.

Allowable Charge: An amount BCBSNE uses to calculate

payment of Covered Services. This amount will be based on

either the Contracted Amount for In-network Providers or the

Out-of-network Allowance for Out-of-network Providers.

Annual Enrollment Month: The month during which

membership additions and deletions are made. This month

usually corresponds to the rating anniversary and must be

mutually agreed upon by the Group Applicant and BCBSNE.

Approved Provider: A licensed practitioner of the healing

arts who provides Covered Services within the scope of his or

her license and who is payable according to the terms of the

Contract, Nebraska law and the direction of BCBSNE.

Bene t Plan Document: The agreement between BCBSNE

and the Group which includes the Administrative Services

Agreement and any attachments or addenda, this Summary

Plan Description, and the individual enrollment information of

Subscribers and their Eligible Dependents.

Certi cation (Certi ed): Successful voluntary compliance

with certain prerequisite quali cations speci ed by regulatory

entities.

98-749 1/2024

Section 10

Coinsurance: The percentage amount the Covered Person

must pay for Covered Services, based on the lesser of the

Allowable Charge or the billed charge.

Consultation: Dental services for a patient in need of

specialized care requested by the attending Dentist who does

not have that knowledge.

Contracted Amount: The payment agreed to by BCBSNE or

an On-site Plan and contracting Providers for Covered Services

received by a Covered Person.

Cosmetic: Any services provided to improve the patient’s

physical appearance, from which no signi cant improvement in

physiologic function can be expected, regardless of emotional

or psychological factors.

Covered Person: Any person entitled to bene ts for Covered

Services pursuant to the Bene t Plan Document administered

by BCBSNE.

Covered Services: Dental procedures, supplies, drugs, or other

dental care services, for which bene ts are payable under the

Bene t Plan Document, while the ASA is in e ect.

Deductible: An amount of Allowable Charges which must be

met for the Covered Person each Calendar Year for Covered

Services before bene ts are payable by the Plan.

Dentist: Any person who is appropriately Licensed and

quali ed to practice dentistry under the law of the jurisdiction

in which the dental procedure is performed and is operating

within the scope of his/her license.

Eligible Dependent: An individual who quali es as a Dependent

of an Employee under Code Section 152 and who is the

Employee’s Adult Designee, the Employee’s Adult Designee

Dependent Child, or the Employee’s Dependent Child. However,

the de nition of Dependent is modi ed to conform with the

underlying Code section for the quali ed bene t. For example,

for purposes of a bene t under Code Section 105, except as

otherwise provided, a Dependent is a Dependent as de ned

under Code Section 152, without regard to Code Section 152(b)

(1), (b)(2), and (d)(1)(B), and any Child (as de ned in Code Section

152(f)(1)) of the Employee who has not attained the limiting age

of 26.

•

The spouse and/or domestic partner of the Subscriber

unless the marriage or domestic partnership has been

ended by a legal, e ective decree of dissolution, divorce

or separation;

•

An Adult Designee, as de ned, and any Adult Designee’s

dependent children, as described below;

•

Children to age 26. “Children” means:

—

natural-born and legally adopted children of the

Subscriber or Adult Designee;

—

stepchildren of the Subscriber;

—

grandchildren, due to court order that require

coverage, who live with and are chie y dependent

upon the Subscriber/Adult Designee for support and

maintenance and for whom the Subscriber/Adult

Designee has obtained legal guardianship;

—

a child for whom the Subscriber or Adult Designee has

legal guardianship.

Appropriate Documentation must be provided to verify

count appointed legal guardian status.

•

Reaching age 26 will not end the covered child’s coverage

under the plan as long as the child is, and remains both

incapable of self-sustaining employment, or of returning

to school as a full-time student, by reason of intellectual or

physical disability; and dependent upon the Subscriber for

the majority of his or her support and maintenance.

“Physical or intellectual disability” means a severe disability

of a person which: a) is attributed to a physical or mental

impairment or combination of physical or mental impairments;

b) is manifested before the person attains age 26; c) is likely

to continue inde nitely; and d) results in incapability of

performing self-sustaining employment.

“Severe disability” means substantial functional limitations in

three (3) or more of the following areas of major life activities:

•

self-care;

•

receptive and expressive language;

•

learning;

•

mobility;

•

self-direction; or

•

capacity for independent living; and re ects the person’s

need for treatment or other services which are of an

inde nite duration and are individually planned and

coordinated.

A physician’s statement may be required.

Proof of the requirements stated above must be received by the

group health plan or BCBSNE from the Subscriber within 31 days

of the child’s reaching age 26 and after that, as required (but

not more often than yearly after two years of such handicap).

Determination of eligibility under this provision will be made

by BCBSNE or the Group. Any extended coverage under this

paragraph will be subject to all other provisions of the Plan.

98-749 1/2024

Section 10

Medicaid: Grants to states for Medical Assistance Programs,

Title XVII of the Social Security Act, as amended.

Medically Necessary or Medical Necessity: Health care

services ordered by a treating Physician exercising prudent

clinical judgment, provided to a Covered Person for the

purposes of prevention, evaluation, diagnosis or treatment of

that Covered Person’s Illness, Injury or pregnancy, that are:

1. consistent with the prevailing professionally

recognized standards of medical practice; and,

known to be e ective in improving health

care outcomes for the condition for which it is

recommended or prescribed. E ectiveness will

be determined by validation based upon scienti c

evidence, professional standards and consideration

of expert opinion, and

2. clinically appropriate in terms of type, frequency,

extent, site and duration for the prevention,

diagnosis or treatment of the Covered Person’s

Illness, Injury or pregnancy. The most appropriate

setting and the most appropriate level of service is

that setting and that level of service, that is the most

cost e ective considering the potential bene ts

and harms to the patient. When this test is applied

to the care of an inpatient, the Covered Person’s

medical symptoms and conditions must require

that treatment cannot be safely provided in a less

intensive medical setting; and

3. not more costly than alternative interventions,

including no intervention, and are at least as likely

to produce equivalent therapeutic or diagnostic

results as to the prevention, diagnosis or treatment

of the patient’s Illness, Injury or pregnancy, without

adversely a ecting the Covered Person’s medical

condition; and

4. not provided primarily for the convenience of the

following:

a. the Covered Person;

b. the Physician;

c. the Covered Person’s family;

d. any other person or health care provider; and

5. not considered unnecessarily repetitive when

performed in combination with other prevention,

evaluation, diagnoses or treatment procedures.

BCBSNE will determine whether services are Medically

Necessary. Services will not automatically be considered

Medically Necessary because they have been ordered or

provided by a treating Physician.

General Anesthesia: A controlled state of unconsciousness,

accompanied by a partial or complete loss of protective

re exes, including loss of ability to independently maintain

airway and respond purposefully to physical stimulation

or verbal command, produced by a pharmacologic or non

pharmacologic method or combination thereof.

Gingivectomy: The excision or removal of gingival tissue.

Group: The employer or entity making providing dental

coverage for its employees/participants pursuant to the

agreement with BCBSNE.

Hospital: An institution or facility duly Licensed by the State

of Nebraska or the state in which it is located, which provides

medical, surgical, diagnostic and treatment Services with

24-hour per day nursing Services, to two or more nonrelated

persons with an Illness, Injury or pregnancy, under the

supervision of a sta of Physicians Licensed to practice

medicine and surgery.

Illness: A condition which deviates from or disrupts normal

bodily functions or body tissues in an abnormal way, and is

manifested by a characteristic set of signs or symptoms.

Implant: An arti cial material grafted or implanted into or on

bone.

Injury: Physical harm or damage in icted to the body from an

external force.

In-network Provider: A health care provider (Physician,

Dentist, or other health care provider) who has contracted with

BCBSNE to provide services as a part of the Preferred Provider

network in Nebraska.

Investigative: A technology, a drug, biological product,

device, diagnostic, treatment or procedure that has not been

Scienti cally Validated. BCBSNE will determine whether a

technology is Investigative.

Late Enrollee: An individual who does not enroll for coverage

during the  rst period in which he or she is eligible, or during a

special enrollment period.

Licensure (Licensed): Permission to engage in a health

profession that would otherwise be unlawful in the state where

services are performed, and which is granted to individuals

who meet prerequisite quali cations. Licensure protects a

given scope of practice and the title.

98-749 1/2024

Section 10

Plan Administrator: The administrator of the Plan as de ned

by ERISA.

Preauthorization/Preauthorized: A determination by Us or

Our designee, that an admission, extension of stay or other

health or dental care service has been reviewed and based of

the information provided, meets the clinical requirements for

Medical Necessity, appropriateness, level of care, or e ectiveness

under the auspices of the applicable health bene t plan.

Preferred Provider: A health care provider (Hospital, Dentist,

Physician or other health care provider) who has contracted

to provide Services as part of the network in Nebraska, or if in

another state, who is a Preferred Provider with the BlueCard

Program PPO network.

Preferred Provider Organization: Panel of Dentists, Physicians

and other health care providers who belong to a network of

Preferred Providers, which agrees to more e ectively manage

health care costs.

Pulpotomy: Surgical removal of a portion of the pulp with

the aim of maintaining the vitality of the remaining portion by

means of an adequate dressing; pulp amputation.

Quali ed Bene ciary: Under COBRA, an individual who

must in certain circumstances, be o ered the opportunity to

elect COBRA coverage under a group health plan. The term

generally includes a covered employee’s spouse or dependent

children who were covered under the group health plan on the

day before a Qualifying Event, as well as a covered employee

who was covered under the group health plan on the day

before a Qualifying Event that is a termination of employment

or a reduction in hours. The term also includes a child born

to or adopted by a covered employee during a period of

COBRA coverage.

Qualifying Event: The circumstances that entitle persons to

elect COBRA coverage.

Root Canal: The portion of the pulp cavity inside the root of

a tooth; the chamber within the root of the tooth that contains

the pulp.

Schedule of Bene ts: A summarized personal document

which provides information about Deductibles, Coinsurance,

special bene ts, maximums and limitations of coverage. It also

indicates the type of Membership Unit selected and whether

or not waiting periods are in e ect. This term also includes the

Schedule of Bene ts Summary.

Membership Unit: The category of persons to be provided

bene ts pursuant to the Subscriber’s enrollment.

•

Single Membership: This option provides bene ts for

Covered Services provided to the Subscriber only.

•

Subscriber-Spouse Membership: This option provides

bene ts for Covered Services provided to the Subscriber

and his or her spouse/domestic partner and Adult

Designee.

•

Single Parent Membership: This option provides bene ts

for Covered Services provided to the Subscriber and his

or her Eligible Dependent children, but not to a spouse/

Domestic Partner or Adult Designee.

•

Family Membership: This option provides bene ts for

Covered Services provided to the Subscriber and his or her

Eligible Dependents.

Other Membership Units may be available as determined by

BCBSNE and the Group.

Noncovered Services: Services that are not payable under

the Plan.

Occlusion: Any contact between biting or chewing surfaces

of maxillary (upper) and mandibular (lower) teeth.

On-site Plan: A Blue Cross and/or a Blue Shield Plan in another

Blue Cross and Blue Shield Association Service Area, which

administers Claims through the BlueCard Program for Nebraska

Covered Persons residing or traveling in that Service Area.

Orthognathic Surgery: Surgery performed to correct facial

imbalances caused by abnormalities of the jaw bones.

Osteotomy: Surgical cutting of bone.

Out-of-network Allowance: An amount BCBSNE uses to

calculate payment for Covered Services to an Out-of-network

Provider. This amount will be based on the Contracted Amount

for Nebraska Providers or an amount determined by the On-site

Plan for out-of-area Providers.

Palliative: Action that relieves pain but is not curative.

Periodontal: Pertaining to the supporting and surrounding

tissues of the teeth.

Physician: Any person holding an unrestricted license who

is duly authorized to practice medicine and surgery, and to

prescribe drugs.

98-749 1/2024

Section 10

BCBSNE will determine whether a technology is Scienti cally

Validated.

Space Maintainer: A passive appliance, usually cemented

in place, that holds teeth in position until the permanent

teeth erupt.

Subscriber: An individual who enrolls for dental coverage and

is named on an identi cation card, and who is:

1. an employee hired by an employer who makes

application for dental coverage for its employees;

2. a retiree quali ed to receive bene ts as de ned by

the Plan; or

3. a COBRA Quali ed Bene ciary.

Temporomandibular Joint (TMJ): The connecting joint

between the base of the skull (temporal bone) and the lower

jaw (mandible).

Schedule of Bene ts Summary: See de nition of Schedule

of Bene ts.

Scienti cally Validated: A technology, a drug, biological

product, device, diagnostic, treatment or procedure is

Scienti cally Validated if it meets all of the factors set

forth below:

1. Technologies, drugs, biological products, devices

and diagnostics must have  nal approval from

the appropriate government regulatory bodies. A

drug or biological product must have  nal approval

from the Food and Drug Administration (FDA). A

device must have  nal approval from FDA for those

speci c indications and methods of use that is being

evaluated. FDA or other governmental approval

is only one of the factors necessary to determine

Scienti c Validity.

2. The Scienti c Evidence must permit conclusions

concerning the e ect of the technology on health

outcomes. The evidence should consist of well-

designed and well-conducted investigations

published in peer-reviewed journals. The quality of

the body of studies and the consistency of the results

are considered in evaluating the evidence.

The evidence should demonstrate that the technology

can measure or alter the physiological changes related

to a disease, Injury, Illness or condition. In addition

there should be evidence based on established

medical facts that such measurement or alteration

a ects the health outcomes.

Opinions and evaluations by national medical

associations, consensus panels or other technology

evaluation bodies are evaluated according to the

scienti c quality of the supporting evidence and

rationale. Our evidence includes, but is not limited

to: Blue Cross and Blue Shield Association Technology

Evaluation Center technology evaluations; Hayes

Directory of New Medical Technologies’ Status; Centers

for Medicare and Medicaid Services (CMS) Technology

Assessments and United States Food and Drug

Administration (FDA) approvals.

3. The technology must improve the net health

outcome.

4. The technology must improve the net health

outcome as much as or more than established

alternatives.

5. The improvement must be attainable outside the

investigational settings.

98-749 1/2024

PLAN INFORMATION

Plan Name: University of Nebraska (Board of Regents of the University of Nebraska)

Group Health Beneﬁ t Plan

Employer: University of Nebraska

217 Varner Hall 3835 Holdrege St

Lincoln, NE 68503-1435

(402) 472-2111

Employer Identiﬁ cation Number: 47-0049123

Type of Plan: Dental

Funding: Self-Funded

Plan Year: January 1 to December 31

Plan Administrator: University of Nebraska

217 Varner Hall 3835 Holdrege St

Lincoln, NE 68503-1435

(402) 472-2111

Type of Administration: Insurer Contract Administration

(Administrative Services Agreement)

Participating Employers: University of Nebraska (Board of Regents of the The University of

Nebraska)

Registered Agent for Service of Legal Process: University of Nebraska

217 Varner Hall 3835 Holdrege St

Lincoln, NE 68503-1435

(402) 472-2111

Service of legal process may also be made upon the Plan

Administrator

Contributions: Employer and Employee

Contract Administration* of this Plan is with: Blue Cross and Blue Shield of Nebraska

1919 Aksarben Drive • P.O. Box 3248

Omaha, Nebraska 68180-0001

(402) 390-1800

Amendment or Termination: University of Nebraska (Board of Regents of The University of Nebraska),

as Plan Sponsor, has the right to amend or terminate the plan at any time

* Blue Cross and Blue Shield of Nebraska provides administrative claims payment services only and does not assume any ﬁ nancial risk or obligation

with respect to claims. Blue Cross and Blue Shield of Nebraska liability may occur only under a stop loss provision set forth in a stop loss

agreement with the Group.

NebraskaBlue.com

Blue Cross and Blue Shield of Nebraska is an independent licensee

of the Blue Cross and Blue Shield Association. 89-064-1 (03-15-21)

Claims administration by