Highlights of dental plan provisions,

rules and procedures

ConnectiCareDental Plans

P R O D U C E R ’ S G U I D E T O

TABLE OF CONTENTS

ConnectiCare Dental Plans1

Dental Plan Designs2-4

Important Guidelines5

Rates and Quote Requests6

New Group Implementation7

Renewals8

Self-service Transactions9

Enrollment10

ID Cards11

Member Services11

Pre-Determination of Benefits12

Claims13

Sample Explanation of Benefits14

Billing Procedures and Premium Payments15

Sample Invoice16

Terminating Coverage17-18

Important Telephone Numbers and Addresses19

CONNE C T I C AR E D EN T A L P L ANS

1

This guide provides an overview ofConnectiCare’s Dental Plans. You’ll find helpful information on plan designs,eligibility, underwriting guidelines andother topics. This guide is not all-inclusive and is subject to change.

ConnectiCare Dental Plans are PPOs, offering the ideal balanceof choice and cost control. And, with the combination ofConnectiCare Dental Plans and Medical Plans, you gain theconvenience of two lines of business with one carrier.

Choices for participants ConnectiCare Dental Plans offer familiar PPO-style, open access to broad, quality provider networks. Participants are free to choose preferred providers, including specialists. Nogatekeepers, no referrals, no paperwork. There’s also coveragefor out-of-network care.

And, the ConnectiCare Dental Premium Network is the thirdlargest in the state.

Cost controls for your clients There’s a range of plans and price points, from value-priced preventive care plans to high-option plans that include orthodontia.You can even offer dual-option and customized plans for largergroups. With efficient administration and automated claims adjudication, ConnectiCare Dental Plans effectively manage costs for large and small groups.

Plans that make senseConnectiCare Dental Plans are designed to be simple and sensible.Our plan designs offer the right range of costs and coveragesand can be matched with a variety of network options.

BeneCareBeneCare, a respected eastern region dental plan administrator,manages ConnectiCare’s suite of dental products. WithBeneCare, your clients can expect a commitment to service and technology, with the goal of fast, accurate claims handlingand smooth, trouble free administration.

ConnectiCare® Dental Plans – Put quality behind your smile

ConnectiCare Dental Plans offerthree network options, each definedby the level of network access andprovider compensation.

Premium Network – the plan for people who want the broadestaccess and coverage that providesreimbursement at approximately 90% of area fees.

Plus Network – the mid-level planthat adds improved provider accessthrough an enhanced network atapproximately 80% of area fees.

Value Network – the most economical network that providesreimbursement at approximately70% of area fees.

Within each network option, clientsin our comprehensive plan optionsmay choose from a number of standard fully-insured benefit plans.

With ConnectiCare Dental Plansthere’s a wide variety of planoptions and price points to meetthe needs of large- and small-employers alike. Customized plansare also available for large groups.In addition, we can duplicate yourclient’s current plan.

These plans are available toConnecticut groups only.

Small-GroupOptionsConnectiCare Dental Plans areavailable for small groups with 3-9 and 10-50 full-time, enrolledemployees. Small-group members willenjoy the same level of benefits aslarge groups with our comprehensivecoverage and competitive pricing.

Groups with 3-9 employees mustpurchase a ConnectiCare medical

plan along with the dental plan tobe eligible for dental benefits.

Groups with 10-50 employees donot need to purchase a ConnectiCaremedical plan to be eligible for dentalbenefits. Dental benefit plans can bepurchased as a stand alone option.

ConnectiCareDental Plans —Basic PlansConnectiCare has a convenient, effective way for small employers tointroduce a dental plan into theirbenefits package. ConnectiCareDental — Basic Plans. Our BasicPlans provide cost-effective plandesigns specifically targeted to meetthe demands of small employers. TheBasic plans are available for smallgroups with 3-9 and 10-50 employeesand provide a $0 deductible with a$1,000 annual maximum and coveragefor preventive and basic services. Thereare plan designs available for all threenetworks — Value, Plus and Premium.

Large-Group Plans Customized PlanDesignsIn addition to a variety of standardplan designs, ConnectiCare canprovide customized plan designs for any group of over 50 eligibleemployees. For example, out-of-net-work benefit levels can be adjustedto meet the employer’s need.

Self-Funded PlansConnectiCare also offers the option to self-fund dental plans for large group sponsors. If yourclient is interested in a self-fundingoption, please contact your

ConnectiCare Sales Representativefor more information.

Voluntary PlansConnectiCare has published voluntary rates available for the 10-50 employee market. This optionprovides your clients with a viablealternative to introduce or maintainquality dental benefits into their benefit portfolios.

Note:All dental plans are administeredon a contract-year basis.

Annual maximumlook back programThis program allows your clients toaccess additional benefit dollars.

Here’s how it works: If your clients’ employees use lessthan 50% of their available annualmaximum in a specific benefit year,they will be able to access up to $250of that remaining benefit if they reachthe annual maximum in the followingbenefit year. That means up to anadditional $250 that can be appliedto their annual maximum creatingmore benefit flexibility and that maximizes their benefit dollars. Some preventive services must beused in the prior year in order to be eligible for the additional $250benefit rollover the following year.

For example:Members who use up to 50% of theiravailable annual maximum in 2011will be able to access as much as $250of the remaining dollars if they reachtheir annual maximum in 2012.Some preventive services must beaccessed in 2011 to be eligible for the benefit rollover in 2012.

Dental Plan Designs

DEN T A L P L AN D E S I GNS

2

Standard PlanExclusions andLimitationsThe following is a list of services,supplies, etc., excluded and/or limited under ConnectiCare Dental Plans.

1. Experimental or investigationalprocedures are excluded.

2. Appliances, restorations, and procedures to alter verticaldimension, including, but notlimited to, occlusal guards andperiodontal splinting are excluded.

3. Space maintainers for dependentchildren age ten or over areexcluded.

4. Services or supplies rendered orfurnished in connection with anyduplicate prosthesis or any otherduplicate appliance are excluded.

5. Restorations which are not of anydental health benefit, but primarilycosmetic treatment in nature,including, but not limited tolaminate veneers and posteriorcomposites are excluded. Paymentof the applicable cost-share ofthis plan’s maximum allowableamount for the alternate service,if any, will be made toward suchtreatment and the balance of thecost remains the responsibility ofthe member.

6. Personalized, elaborate, or precisionattachment dentures or bridges, orspecialized techniques, includingthe use of fixed bridgework, wherea conventional clasp designedremovable partial denture wouldrestore the arch are excluded.Payment of the applicable cost-share of this plan’s maximumallowable amount for the alternate

service, if any, will be madetoward such treatment and thebalance of the cost remains theresponsibility of the member.

7.General anesthesia, except for thefollowing reasons, is excluded:

a. Removal of one or moreimpacted teeth;

b. Removal of four or moreerupted teeth;

c. Treatment of a physically ormentally impaired person;

d. Treatment of a child under age 11; and

e. Treatment of a member whohas a medical problem, whenthe attending physicianrequests in writing that thetreating dentist administergeneral anesthesia. Thisrequest must accompany the dental claim form.

8.Duplicate charges are excluded.

9. Services incurred prior to theeffective date of coverage areexcluded.

10. Services incurred after cancellation of coverage, or loss of eligibility are excluded.

11. Services incurred in excess of the benefit year maximum are excluded.

12. Services or supplies that are not dentally necessary accordingto accepted standards of dentalpractice are excluded.

13. Services that are incomplete are excluded.

14. Orthodontic services for persons age 19 or over, whenorthodontics is a covered dentalservice are excluded.

DEN T A L P L AN D E S I GNS

3

Standard PlanExclusions andLimitations, continued15. Sealants on teeth other than the

first and second permanentmolars, or applications appliedmore frequently than every thirty-six months or a serviceprovided outside of ages fivethrough fourteen are excluded.

16. Services such as trauma whichare customarily provided under medical-surgical coverageare excluded.

17. More than two oral examina-tions in any 12-month periodare excluded.

18. More than two prophylaxes in any 12-month period are excluded.

19. More than one full mouth X-ray series in any period of 36 consecutive months is excluded.

20. More than one bitewing X-rayseries in any 12-month periodis excluded.

21. Adjustments or repairs to dentures performed within sixmonths of the installation ofthe denture are excluded.

22. Services or supplies in connectionwith periodontal splinting are excluded.

23. Expenses incurred for thereplacement of an existing denture which is or can bemade satisfactory are excluded.

24. Expenses incurred for a temporary denture are excluded.

25. Expenses incurred for thereplacement of a denture, crown,or bridge for which benefitswere previously paid, if suchreplacement occurs within five years from the date theexpense was originally benefitedare excluded.

26. Training in plaque control ororal hygiene, or for dietaryinstruction is excluded.

27. Completion of reporting formsis excluded.

28. Charges made by the attendingdentist for the member’s failureto appear as scheduled for anappointment are excluded.

29. Charges for services and supplieswhich are not necessary fortreatment of the injury or disease,or are not recommended andapproved by the attending dentist, or charges which arenot reasonable are excluded.

30. Scaling and root planing whichis not followed, where indicated,by definitive pocket eliminationprocedures are excluded. In theabsence of continuing periodontaltherapy, scaling and root planingwill be considered a prophylaxisand subject to the limitations ofthat procedure and are excluded.

31. Periodontal surgery proceduresmore than once per quadrant inany period of 36 consecutivemonths are excluded.

32. More than one periodontal scaling and root planing perquadrant in any consecutive 36month period is excluded.

33. More than two periodontalmaintenance procedures in anyconsecutive 12-month periodare excluded. In the absence of benefited comprehensiveperiodontal therapy, periodontalmaintenance procedures are excluded.

34. Services for any condition covered by workers’ compensationlaw or by any other similar legislation are excluded.

35. Claims submitted more than 11 months (335 days) followingthe date of service are excluded.

DEN T A L P L AN D E S I GNS

4

IMPOR T AN T GU ID E L IN E S

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Important GuidelinesPlease note the following guidelines for employer sponsors and employee eligibility for ConnectiCare Dental Plans.

EligibilityRequirementsWondering who is eligible for member-ship? The plan covers employees, andeligible family members such as spousesand children.

Who is eligible for membershipunder the plan?

Subject to the Employers rules,employees working 30 hours or

more per week are eligible. Theemployer must be domiciled in Connecticut.

Spouses• The spouse of an employee is also eligible for coverage if the employeeand spouse are in a legally valid existingmarriage and the spouse resides withthe employee, or in the service area.

• A partner under a legally valid civil union recognized by the State of Connecticut who resides with the employee.

ChildrenChildren under age 26 who meet oneof the conditions/criteria below and arenot enrolled as employees on a grouphealth plan. However, if that grouphealth plan is a self-funded plan with aprivate employer, the under 26 agedependent may remain eligible underthis plan, if he or she chooses to:

• Natural children.

• Adopted children who are legallyadopted by the employee and meetthe requirements for natural childrenonce the adoption is final. Before theadoption is final, the children are eligible for coverage when youbecome legally responsible for atleast partial support.

• Stepchildren who are natural oradopted children of your spouse, orfor whom your spouse is appointedlegal guardian.

• Children for whom the employee orspouse are appointed legal guardians.

Coverage for children enrolled inConnecticut Group Plans will end onthe last day of the month following themonth in which the child:

• Becomes covered under his/her own group insurance plan, see exception above;

• Turns age 26.

Coverage for handicapped childrenmay be extended beyond the age whenit would normally end if the children:

• Reside in the Service Area or withthe employee;

• Are unable to support themselves by working because of a mental orphysical handicap as certified by the children’s physician;

• Are chiefly dependent on theemployee or spouse for support and maintenance due to the mentalor physical handicap; and

• Have become and continuouslyremained handicapped while they would have been eligible for dependent children coverage if they were not disabled.

Underwriting Guidelines• The minimum group size is three enrolled employees. Minimum participation is three employees forgroups of three to nine employees and10 employees for groups of 10 or more.

• Prospective groups must be domiciledin Connecticut.

• The employer sponsor must contributea minimum of 50% of the premium forsingle subscribers and a minimum of25% of the premium for dependents.(Note: there is an exception forVoluntary Plan Options.)

Additional underwriting guidelinesfor comprehensive plans 10-50 enrolled employee-sized groups• The following groups are NOT eligiblefor coverage under the ConnectiCareDental Plans small group rates without underwriting approval:

− Groups without prior dental coverage

− Groups in the following industrieswill not be underwritten withoutapproval:

Legal services (SIC 8100-8199)

Educational services (SIC 8200-8299)

Social services (SIC 8300-8399)

Membership organizations (SIC 8600-8699)Justice, public service and safety (SIC 9200-9299)

• Effective dates for coverage are the 1st of the month.

• COBRA will be administered by the group.

Additional underwriting guidelinesfor Basic Plans 3-9 and 10-50enrolled employee-sized groups • There are no SIC restrictions

• The Basic plan can be sold to groupswith no prior coverage

Additional underwriting guidelinesfor 3-9 enrolled employee-sized groups • There are no SIC restrictions

• Groups must purchase a ConneciCaremedical plan to be eligible forConnectiCare Dental Plans

• Can be sold to groups with no prior coverage

Small-Group – Employer Sponsors with 3-50 Enrolled EmployeesSmall-group rates are available on the ConnectiCare Web site at www.connecticare.com. Producers may also obtainquotes on Benefit Central at www.benefitcentral.com.

Small-group quote requests may also be obtained by completing a Small-Group Quote Request form, found on theDental page “forms section” of the producer Web site, including all required information, and submitting it toConnectiCare via fax or e-mail as noted on the form. E-mailing quote requests will result in the most efficient responsetime from ConnectiCare.

Large-Group – Employer Sponsors with more than 50 Enrolled EmployeesQuotes for large groups may be obtained by completing a Dental Plan Quote Request form, found on the Dental page“forms section” of the producer Web site, and submitting it to ConnectiCare with all required information. Quoterequests may be sent via fax or e-mail as noted on the form. E-mailing quote requests will result in the most efficientresponse time from ConnectiCare.

RA T E S AND QUO T E R E QUE S T S

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Rates and Quote RequestsImportant Note Regarding Producer Appointment: Producers must be appointed with ConnectiCare in orderto quote and sell ConnectiCare Dental Plan products. If you are not a ConnectiCare appointed producer,Appointment Packets are available on the ConnectiCare Web site at www.connecticare.com.

All plans are administered on a contract-year basis.

Small-Group –Employer Sponsorswith 3-50 EnrolledEmployeesSmall-group employer sponsorsshould complete the Small-GroupEmployer Application and send it to Small-Group Sales with a checkfor the first month’s premium andcompleted Enrollment Applications.Once the Employer Application isreviewed and the group is accepted,BeneCare will produce the Evidenceof Agreement and return it to the producer.

Enrollment materials, including the Enrollment Applications, areavailable on the ConnectiCare Website at www.connecticare.com.

Large-Group –Employer Sponsorswith more than 50Enrolled EmployeesLarge-group employer sponsors who select a ConnectiCare DentalPlan should confirm their selectionby signing and returning toConnectiCare one copy of theEvidence of Agreement along with acheck for the first month’s premium.

Your ConnectiCare SalesRepresentative will then work with you and the employer sponsor to coordinate the enrollment process to insure that it goes smoothly. Enrollment materials may be ordered online at www.connecticare.com orthrough your representative.

New Group Implementation

NEW GROUP IMP L EMENT A T I ON

7

Enrollment materials may be ordered online atwww.connecticare.com orthrough your representative.

Once employees have enrolled in the plan, they will receive a DentalPlan ID card (one card per family) benefit summary and Certificate ofCoverage at their home.

All new employer sponsors will receive a Welcome Kit from ConnectiCareDental Plans that includes an Administrative Guide with important telephone numbers and addresses as well as helpful information on anumber of administrative topics.

Renewals

RENEWAL S

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Large Groups (50+enrollees) renewals

Rates are determined based on anumber of different factors, including: changes in group sizeand enrollment; claims experience;expected changes in the cost ofdental services; and expectedchanges in utilization. Renewals are sent to the ConnectiCareaccount manager if the renewal is acombined medical/dental package.Renewals are sent directly to theproducer if dental only customers.

Small Groups (10+enrollees) renewals

Rates are determined based on a number of different factors, including: changes in group sizeand enrollment; claims experience;expected changes in the cost ofdental services; and expectedchanges in utilization. Renewals are sent from BeneCare to the producer and the group 60 daysprior to renewal.

Small Groups (3-9enrollees) renewals

This segment is community rated.Rates are determined based on anumber of different factors of thegroup, as well as the other groupsin this rating segment or block ofbusiness. They include changes ingroup size and enrollment; claimsexperience; expected changes in the cost of dental services; andexpected changes in utilization.Rate change notifications are sentfrom BeneCare to the producer and the group 60 days prior torenewal. Rates change for all groupsat the same time. Prior notificationis provided.

S E L F - S E R V I C E T R ANS A C T I ONS

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Self-service transactions As a ConnectiCare Dental Planssponsor, your clients have access towww.benecare.com. This Web sitehas been designed to make benefitadministration easier, saving themtime in gathering information ontheir plans while minimizing effortswith other requests. Within thesponsors’ secure section ofwww.benecare.com your clients will find the following useful toolsfor administering their benefits:

• manage the group’s contact information;

• submit enrollment and eligibilitychanges;

• download a printable claim form;

• retrieve real time reports of subscribers and their dependents;

• view or print a dental benefitdescription for the plan;

• locate participating BeneCaredentists by specialty and distance;

• assist subscribers with claimsinquiries; and

• manage their www.benecare.comaccount profile.

Your clients’ subscribers (employeesand/or their dependents) can alsoaccess www.benecare.com. They can:

• locate participating BeneCaredentists by specialty;

• access information about theirdental claims;

• view or print a dental benefitdescription for their plan;

• access a variety of resources andlinks for oral health information;

• download a printable claim form;and

• manage their www.benecare.comaccount profiles.

administered byBeneCare Dental Plans

Your selection must be offered by your Sponsor.

1. Enrollment

New Subscriber

Effective Date

A. Type of Activity - To Be Completed by Sponsor

Refer to instructions on back before completing this form. Print clearly.Subscriber Group Information - To Be Completed by Sponsor

Group Name

2. Change - Check all that apply

Add SpouseAdd Dependent ChildName ChangeChange PlanOther

Date of Event 3. Remove or Terminate Check all that apply

4. Continuation of Coverage, i.e., COBRA

Remove SpouseRemove Dependent ChildSubscriber Withdraw l/Termination

NOTE: Subscriber must be enrolled for spouse/dependent(s) to have coverage.

Coverage For:

Length of Continuation:

Date of Loss of Coverage:

Date of Qualifying Event:

Subscriber Dependents

12 mos 18 mos 36 mos29 mosDate of Hire

B. Subscriber Information - Complete Sections B - G.Social Security Number

Home Address

Sponsor Name

Work Address

Last Name, First Name, M. I.

Apt. No. ZIP Code

Home Telephone

( )

Work Telephone

( )

City, State

C. Plan Option

Please write in plan selection if morethan one plan is being offered.

D. Individuals Covered - List individuals for whom you are adding/changing/removing coverage. Attach sheet to list add'l. children.

Subscriber

Spouse

Child

Child

Child

(A)dd(C)hange(R)emove Last Name, First Name, M.I.

SexM / F

BirthdateSocial SecurityNumber MM / DD / YYYY

E. Other Dental Insurance

Is your Spouse Employed? Yes NoIf "Yes", give name & address of spouse's employer.

If spouse or dependents have other dental coverage, give name a policy number of insurance carrier,HMO or other source.

Enrollment/Change Request

F. Subscriber Signature

Subscriber Signature - Required

I represent that all of the information supplied in this application is true and complete. G. Sponsor Verification - To Be Completed by Sponsor

Sponsor Signature - Required Title

If you have questions concerning the benefits and services provided by or excluded under the Plan, contact a Member Servicesrepresentative at 1-888-843-4727 before signing this form.

Subscriber copy may be used as a temporary ID card for 30 days from the effective date if authorized by the Sponsor. Form # dentalcareEF 0

Effective Date

City, State ZIP Code

Date Date

Type of activity: Checkbox(es) indicating reason(s)for submitting application.

Subscriber Information:Complete all informationin order for your applica-tion to be processed.

Plan Option: •Indicate Plan OptionName (where applicable).

Individuals Covered:•Add/Change/Remove - Use “A”, “C”, or “R” to indicate whether you are adding, changing or removing coverage for an individual.•Print your full name along with the name(s) of your dependent(s), if applicable. Indicate sex, birthdate, and Social Security Number for each individual listed.

Other Dental Insurance:•If you or your depend-ent(s) have other dental coverage, check off the “Yes” box(es) and complete Section E - Other Dental Insurance.

• Complete this section forall new enrollments or coverage changes.

Subscriber Signature:• Complete this section for all new enrollments, coverage changes and terminations.

• Subscriber must sign and date the application in order for it to be processed.

Sponsor Verification:• Sponsor must complete this section for all new enrollments, coverage changes and terminations.

• Sponsor must sign and date the application in order for it to be processed.

ENROL LMENT

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All eligible employees must enroll by filling out and signing a ConnectiCare Dental Plan Enrollment Application. All applications must be complete and must be signed by the employer sponsor. Completed applications should bereturned to your ConnectiCare Sales or Account Management Representative.

We will also accept electronic forms of enrollment. Please contact BeneCare at 1-800-426-0947 to discuss data formatsand procedures.

Enrollment

A

B

C

SAMPLE ENROLLMENT FORM

DE

F

A

B

C

D E

F

G

G

Members with inquiries and questionsabout ConnectiCare Dental Planeligibility, ID cards, claims, or thedental network should contactMember Services at 1-888-843-4727.You can also go to our Web site, atwww.connecticare.com and clickon Find a Doctor, our online participating provider directory.

Most questions and complaints can be resolved informally. If amember has a question or a complaint, the first step should be to contact Member Services bytelephone or, members can write to ConnectiCare Dental Plans at:

Member ServicesConnectiCare175 Scott Swamp RoadFarmington, CT 06032-3124

If a question or complaint cannotbe resolved informally, the membermay use the appeals process. Thisprocess is available to members who disagree with a decision maderegarding covered benefits or claims processing. Please see theCertificate of Coverage or otherplan document for more detailsabout the appeals process.

ID Cards

I D C A RDS / M EMBER S E R V I C E S

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Premium

Administered byBeneCare Dental Plans

ID#: CT0000100 Effective Date: 7/01/2004JANE SAMPLE2 SOME STREET#5ANYTOWN CT 06700Group Name: CONNECTICARE Group Number: 750

Sample ID Card

ID number

Effective date

Name and address

Employer group name

Employer group number

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DENTAL PLAN ID CARD

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2

1

Members should provide the ConnectiCare Dental Plan ID number, group name and group number to the dentist tofacilitate billing.

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Member Services

Pre-Determination of Benefits

PRE - D E T ERM INA T I ON O F B ENE F I T S

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When dental services are expectedto exceed $300, or when servicessuch as orthodontics, dentures,crowns, periodontics or bridgeworkare required, it is recommendedthat dentists submit a request toBeneCare for a pre-determinationestimate of covered benefits. Whilethere is no explicit prior approvalrequired to obtain benefits, thisstep protects both the member andthe dentist by advising in advancewhat portion of dental treatmentcosts will be covered. This is a common practice with dental plansand requires no action on the partof the member.

While there is no explicit prior approval requiredto obtain benefits, this step protects both the member and the dentist by advising in advancewhat portion of dental treatment costs will be covered. It can help to plan when to have treatment and what the costs may be.

Care Received from ParticipatingProvidersParticipating providers will billConnectiCare directly for coveredservices. Members are responsibleonly for the applicable deductibles,coinsurance amounts, or copayments.

Care Received fromNonparticipatingProvidersMembers may receive services fromdentists who do not participate inthe ConnectiCare Dental Plan networks. Nonparticipating dentists may submit claims on the member’s behalf or they mayrequest payment at the time ofservice, in which case the memberis responsible for submitting theclaim for reimbursement. Membersare responsible for any deductible,coinsurance, and balance remainingafter reimbursement is made by ConnectiCare up to the billed charges.

All claims must be submitted nolater than 335 days following thedate of service. Claims mustinclude, at a minimum, the following information to be considered for reimbursement:

• The subscriber’s name.

• The name of the person whoreceived services and theirConnectiCare Dental Plan ID number.

• A complete itemized bill thatincludes a description of the service and the appropriate ADACurrent Dental Terminology(CDT) code, the date service wasrendered, the treatment details,and the charges.

• Please note that credit cardreceipts and “balance due” statements are not acceptable.

Claims should be submitted to:

ConnectiCare Dental Plans

c/o BeneCare

615 Chestnut Street, Suite 1001

Philadelphia, PA 19106-4404

Coordination of BenefitsIf a member is eligible to receivebenefits under another plan —including group dental plans, andWorkers’ Compensation —Coordination of Benefits will apply.A member’s ConnectiCare benefitswill be coordinated with the otherplan’s benefits.

When ConnectiCare Dental is thesecondary plan, the member mustsend a copy of the Explanation ofBenefits (EOB) form received fromthe primary dental plan, along withthe claim form. If the claim isreceived without an EOB from the primary carrier, the claim will be denied. It is the member’s responsibility to ensure that theclaim is processed by the primaryplan. If ConnectiCare is the secondarycarrier, the member has 335 days(11 months) from the date the primary carrier processed the claimto submit the claim to ConnectiCare.The rules and guidelines forCoordination of Benefits aredescribed in the Certificate ofCoverage or other plan document.

Claims

C L A IMS

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Participating providers will bill ConnectiCaredirectly for covered services. Members are

responsible only for the applicable deductibles,coinsurance amounts, or copayments.

Joe Jones

1 Any Street

Apt. 1

Anytown, CT 06000

Administered by BeneCare

THIS IS NOT A BILL

The following Explanation of Benefits is provided for your

information. Should you have any questions, or believe

that any of the detail is incorrect, please contact the

program administrator at the address shown below.

Group Name: Connecticare Claim: 1234567

Patient Name: Joe Jones Dentist Name: Robert Smith

Procedure

Description

Service

Date

Doctor’s

Fee

Covered

Fee

Percent

Covered

Plan

Payment

Ex.

No

Exclusion

Description

PERIODIC EXAM 1/1/2005 40.00 40.00 100 40.00

BW 2 FILMS 1/1/2005 40.00 40.00 100 40.00

ADULT PROPHY 1/1/2005 70.00 70.00 100 70.00

AMALGAM 2 SURF 1/1/2005 110.00 110.00 80 0 22 DUP. CHARGES NOT COVERED BENEFITS

AMALGAM 3 SURF 1/1/2005 170.00 160.00 80 128.00

DEDUCTIBLE 50.00

TOTAL 228.00

MEMBER RIGHTS TO APPEAL

You have the right to appeal a denied claim up to 180 days after the initial denial by writing to ConnectiCare Dental

Plans Appeals, 175 Scott Swamp Road, Farmington, CT 06032. For complete information on the appeals process,

please refer to your Dental Certificate of Coverage. If you do not file your appeal in a timely manner, you may lose

your right to challenge the decision. If your plan is subject to ERISA, you may have the right to bring a civil action

under Section 502(a) of the Employee Retirement Income Security Act if your claim is not approved. For assistance

with filing an appeal, contact Member Services at 1-888-843-4727.

IF YOU SUSPECT FRAUD

Any person who, knowingly and with intent to defraud ConnectiCare or its members, files a statement of claim

containing any materially false information, or conceals for the purpose of misleading, information concerning any fact

material thereto, is guilty of committing a fraudulent insurance act, which is a crime punishable in accordance with

applicable law. If you suspect fraud, call ConnectiCare’s Special Investigative Unit at 1-800-349-2833.

615 Chestnut Street, Suite 1001

Philadelphia, PA 19106-4404

(215) 440-1000

(215) 440-1021 Fax

Ex. No. and Exclusion Description – Further explanation, if necessary, as to how the claim was paid or declined for coverage

Deductible – any deductible amount owed by the member for theservices rendered according to the benefit schedule in the Certificateof Coverage or other plan document

Total – the total amount paid by the plan for this claim

S AMPL E E X P L ANA T I ON O F B ENE F I T S

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Explanation of Benefits (EOB) Statement

This is not a bill – This is areminder that the Explanation of Benefits is not a bill. It provides information on how a claim is paid

Group name – The name of theemployer sponsor

Claim number – The internalnumber used by the plan to identify this claim

Patient name – The name of the patient for whom services were rendered

Dentist name – The name of the dentist that rendered services

Procedure description – Adescription of the dental services rendered

Service date – The date serviceswere rendered

Doctor’s fee – The amount billedby the dentist providing services

Covered fee – The amountallowed by the plan for the services rendered

Percent covered – The percentageof the covered fee that is paid bythe plan according to the benefitschedule in the Certificate ofCoverage or other plan document

Plan payment – The dollaramount that the plan will pay forthe services rendered based on thecovered percent of the covered fee

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SAMPLE EXPLANATION OF BENEFITS STATEMENT

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Members will receive an Explanation of Benefits (EOB) statement whenever a claim is submitted for payment andprocessed according to benefits, rules and guidelines described in the Evidence of Coverage or other plan document.(Nonparticipating providers will not receive an EOP when submitting a claim that is denied.)

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Dental Plans

15

Billing Procedures andPremium PaymentsHere are important rules and guide-lines regarding premium billing andpayments.

• Employers will receive an invoiceon a monthly basis detailing thepremium due on or about the10th of the month in the monthfor which premium is due.

• The “Please Pay This Amount”,which is the total premium due, isdue and payable upon receipt.

• Eligibility changes may not appearon the bill if ConnectiCare doesnot receive and process theEnrollment/Change Form beforethe Invoice Date (the date the billis produced.)

• Payment, along with the invoice'spayment voucher, should be sentto the lockbox address noted onthe voucher. Premium paymentmay be sent via overnight mail tothe ConnectiCare LockboxAddress on the invoice using theUnited States Postal Service (USPS.)Private carriers (Fed Ex, UPS,etc.) cannot deliver to a P.O. Box.

• Enrollment forms should be sentseparately to:

ConnectiCarec/o BeneCare 615 Chestnut Street, Suite 1001Philadelphia, PA 19106-4404.

• The billing system works on a“wash method” for new hires, inaccordance with the followingConnectiCare new hire eligibilityand termination guidelines:– New hires and additions — Ifthe effective date is on or beforethe 15th of the month, we willbill for the entire month. If theeffective date is after the 15th,there will be no premiumcharge for that month.

– Terminations — If the termination date is on or beforethe 15th of the month, therewill be no premium charge forthat month. If the terminationdate is after the 15th, we willbill for the entire month.

• Retroactive changes will only be allowed up to 60 days calculated from the date on which ConnectiCare receives notification of change.

B I L L ING P R O C EDURE S AND P R EM IUM PA YMENT S

S AMPL E I N V O I C E

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Sample Invoice

Total Number of EmployeesTerminated – The total number ofemployees terminated since the lastinvoice

Tiers and Premium RateCalculations – The total numberof employees per premium tier, the premium amount and monthlytotal

Composite Rate – The total number of employees and composite rate

Retroactive Premium Adjustmentfor Additions – Premium adjustments resulting from retroactive additions

Retroactive PremiumAdjustments for Terminations –Premium adjustments resultingfrom retroactive terminations

Please Pay This Amount – Totalamount due to be paid includingthe monthly premium and alladjustments

Statement as of – The date the statement was produced – premium payment is due in themonth the statement was produced

Remittance Address – Premiumpayments should be sent to thisaddress

SAMPLE INVOICE

Sponsor Name and Number – The company’s name and sponsor number

Invoice Number – The company’s sponsor number and billing monthand year

Total Number of Employees Added – The total number of employeesadded since the last invoice

1

2

3

4

5

6

7

8

9

10

11

Administered byBeneCare Dental Plans

ABC CompanySponsor Number: 123 Invoice Number: 12301012005

Total Number of Employees Added 4

2Total Number of Employees Terminated

Number of EligibleEmployees for 1/2005

Monthly Rate Total Monthly Amount

Employee Only

Two Party

Family

Total # of Employees Total Monthly Amount

26

13

20

59

$ 25.65

$ 53.06

$ 85.47

$ 666.90

$ 689.78

$ 1,709.40

$ 3,066.08

Divided By Total Number of EmployeesEquals Composite Rate

59$51.96

Retroactive Added Amount

Retroactive Terminated Amount

$51.30

$25.65-

$ 3,091.73Please Pay This Amount for the Month of 1/2005

This Statement Reflects All Changes, Terminations, and Added Eligibility Received Through 1/05/2005

PLEASE REMIT THE ABOVE AMOUNT TO:

ConnectiCare, Inc. & AffiliatesP.O. Box 33402Hartford, CT 06150-3402

12

3

4

5

6

7

8

9

10

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Group CoverageIf an employer group wishes to terminate its group policy, writtennotification must be provided toConnectiCare 30 days before theidentified termination date. Thesigned notification must be submittedon company letterhead with thesignature of the authorized grouprepresentative and include the daterequested for termination of thepolicy. Please note that a group termination is effective the last day of the month requested.

In addition, group policies will terminate on the earliest day thatany of the following events occur:• At the end of the grace period, ifthe employer fails to make anypremium payments that are due,or at another date after the graceperiod that we specify in writing.

• If the company commits fraud orwillfully conceals or misrepresentsany material fact or circumstancein applying for coverage withConnectiCare.

• In the event the employer fails to comply with employer contribution requirements orgroup participation rules.

• In the event that ConnectiCareterminates coverage for allemployers in accordance withapplicable state law.

• In the event the employer’s membership in a bona fide association through which coverage is provided ceases.

• On the date the company is liquidated, ceases to operate or no longer covers or employs anyeligible employees.

• On the date agreed upon by thecompany and ConnectiCare.

The above is a summary of grouptermination rules. For more detailedinformation, please refer to theCertificate of Coverage or otherplan document.

Member-InitiatedTermination ofCoverageEmployees or dependents who wantto terminate their coverage mustsubmit the request to their employerin writing within 30 days of theevent effecting coverage.

The employer must: • Complete and sign anEnrollment/Change Form, or

• Write a letter that indicates themember’s name, identificationnumber, termination date andreason for termination.

The employer must then submitthe Enrollment/Change Form toConnectiCare requesting terminationor submit the change on their electronic eligibility update file.

Eligibility changes may not appearon the next bill if ConnectiCaredoes not receive the Enrollment/Change Form before the next bill isproduced. Membership terminationscan be processed retroactively up to60 days, as long as no plan benefitswere provided to the member for thatperiod. If plan benefits were providedafter the date of requested termination,ConnectiCare will adjust the request-ed termination to reflect coverageduring the utilization period andseek premium for that period.

COBRAContinuationCoverageIn accordance with the federalConsolidated Omnibus BudgetReconciliation Act of 1985 andConnecticut state law (referred tohere as COBRA), subscribers andmembers must be offered theopportunity to continue theirgroup coverage when it ends forcertain reasons. Connecticut statelaw also mandates that COBRArights and privileges will apply toall employers covered byConnectiCare, regardless of theemployer size or whether theemployer’s plan is subject to ERISAor COBRA.

The employer is responsible fornotifying members of theirCOBRA rights and administeringthe COBRA rules.

Outlined on page 18 are theCOBRA provisions that pertain to continuing coverage.

Terminating Coverage

17

T ERM INA T ING C O V ERAGE

The Right toContinue Coverage• COBRA gives subscribers andmembers the right to continuecoverage when it ends because of a “qualifying event,” such as a layoff, reduction in work hours or termination of employment,death, or divorce. Coverage forsubscribers and members may becontinued for up to 18, 29 or 36months, depending on the type of qualifying event involved.

• Coverage may be continued for up to 18 months (30 months forsubscribers and members enrolledin ConnectiCare, Inc.) when it endsdue to the subscriber’s reduction in work hours, leave of absence orhis/her employment is terminatedfor reasons other than gross misconduct.

• For a disabled person, coveragemay be continued from 18 to 29months as long as that personmeets certain requirements. Seethe appropriate Certificate ofCoverage, or other plan documentfor more details.

• Coverage may be continued for upto 36 months for:

– A covered child who is no longeran eligible dependent;

– A covered spouse and dependentsif the subscriber dies;

– A covered spouse if the subscriber and spouse divorce orseparate; or

– A covered spouse and dependentsif coverage ends when the subscriber becomes eligible for Medicare.

States may have additional continuationof coverage rules. Members shouldreview their Certificate of Coveragefor more details.

T E RM INA T ING C O V ERAGE

18

IMPOR T AN T T E L E PHONE NUMBER S AND ADDRE S S E S

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ImportantTelephone Numbers ConnectiCare Dental Plan Sales For information about the Dental product, please call yourConnectiCare Sales Representativeor call 1-800-723-2986.

Member Services For information about membership, ID cards, benefits,claims or providers please call 1-888-843-4727.

Enrollment QuestionsFor questions aboutmember/dependent eligibility ormembership verification, please call 1-888-843-4727.

Premium BillingFor questions regarding premiumbills, please call 1-888-843-4727.

ImportantAddressesEnrollment Forms For initial enrollment, please returnforms to your ConnectiCare Salesor Account ManagementRepresentative. For new employeeor changes, please send forms toBeneCare at:ConnectiCare Dental Plans c/o BeneCare615 Chestnut Street, Suite 1001Philadelphia, PA 19106-4404

Premium Payments ConnectiCareP.O. Box 33402 Hartford, CT 06150-3402

Dental ClaimsConnectiCare Dental Plans c/o BeneCare615 Chestnut Street, Suite 1001Philadelphia, PA 19106-4404

Member Complaints/Appeals Member ServicesConnectiCare175 Scott Swamp RoadFarmington, CT 06032-3124

Don’t forget to visit the Producer page of ourweb site at www.connecticare.com to accessplan design and rate information, forms, andother important information aboutConnectiCare Dental Plans.

175 Scott Swamp Road, Farmington, CT 06032www.connecticare.com

© 2011 ConnectiCare Insurance Company, Inc.BeneCare is a registered trademark of Dental Benefit Management, Inc.

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