Denali Individual Dental All Other States_AETNA

7/31/2019 Denali Individual Dental All Other States_AETNA

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Discoverthe Dental Insurance Plan thathelps youreach new

heights.

Higher Level Dental Carewww.denalidental.com

one life plan

Fo r I nd i v i dua l s , Fam i l i e s and Sen i o r s

Indemnity and PPO

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

ALL OTHER STATES


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A Dental Insurance Planfor You and Your Family

Covered ServicesGood oral health is important. Thats why theres Denali Dental.Dont have employer dental coverage? No problem. Denali Dentalallows you to select your own dentist, and is affordable for you andyour family.

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

Preventive Services

Two exas per year Three cleaigs per caledar year

Diagnostic Services

Oe series of bitewig x-rays per year Flouride treatets liited to depedets uder age 19

Basic & Major Services Siple extractios Oe diagostic x-ray, full or paoraic i ay 3 year period Oral surgery Edodotic treatet Periodotic services Restoratio services; ilays, olays ad crows Prosthetic services; bridges ad detures Veeers Edosteal iplats Basic filligs

BeneitsCalendar Year Maximum $1,500, $2,500 or $3,500

per insuredLietime Deductible $100 per person/

$300 per family

REASONABLE AND CUSTOMARY

Dental expenses are paid based on a percentage of Reasonableand Customary (R&C) fees. This means the most common charge fsimilar professional services, drugs, procedures, devices, suppliesor treatment within the Geographic Area in which the charge isincurred. The most common charge means the lesser of:

the actual aout charged by the provider; the egotiated rate; the usual charge which would have bee ade by a provider

(Dentist, Hospital, etc) for the same or a comparable professionaservices, drugs, procedures, devices, supplies or treatment withithe same Geographic Area, as determined by Us.

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

APPLYING

Send all original forms to:

Direct Beneits, Inc.

325 Cedar Street Suite 800,St. Paul MN 55101651-649-3503 / 800-620-5010651-649-3502 [email protected]

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

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Ideity Choose Your Ow Detist

Covered Services

100%

Year 1 100% 70% 10%

Year 2 100% 80% 50%

Year 3 100% 90% 50%

50%

0%PreventiveServices*

100% 100% 100%

Basic & MajorServices*

10%

50% 50%

DiagnosticServices*

70%

80%

90%

www.directbenefits.com


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Covered Services

100%

Year 1 100% 40% 20% 10%

Year 2 100% 80% 50% 25%

Year 3 100% 90% 60% 50%

50%

0%PreventiveServices*

100% 100% 100%

Basic & MajorServices*

20%

50%60%

DiagnosticServices*

40%

80%

90%

OrthoServices

10%

25%

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A Dental Insurance Planfor You and Your Family

Covered ServicesGood oral health is important. Thats why theres Denali Dental.Dont have employer dental coverage? No problem. Denali Dentalallows you to select your own dentist, and is affordable for you and

your faily. Choose the PPO pla ad save o out-of-pocket costswhe visitig a i-etwork provider.

This Dental Insurance Plan helps you cover the costs of dentalcare. Covered dental services include exams, cleanings, fillingsand extractions, as well as crowns, bridges and dentures. Thispolicy pays you for covered dental expenses based upon thereiburseet schedule of the PPO etwork fees for those coveredexpenses after the $100 lifetime deductible has been satisfied.These percentages are: 100% for Preventive Services, 40% forDiagnostic Services, 20% for Basic & Major and 10% for ChildOrthodotia Services i the 1st year. I the 2d year of coverage,Diagnostic Services increase to 80%, Basic & Major Servicesicrease to 50% ad Child Orthodotia icreases to 25%. I the3rd year Diagnostic Services increase to 90%, Basic and Majoricrease to 60% ad Child Orthodotia icreases to 50%.

Preventive Services

Two exas per year Three cleaigs per caledar year

Diagnostic Services

Oe series of bitewig x-rays per year Flouride treatets liited to depedets uder age 19

Basic & Major Services Siple extractios Oe diagostic x-ray, full or paoraic i ay 3 year period Oral surgery Edodotic treatet Periodotic services Restoratio services; ilays, olays ad crows Prosthetic services; bridges ad detures Veeers Edosteal iplats Basic filligs

* Pla B PPO i- ad out-of-etwork subject to Aeta schedule.For Aeta PPO providers please visit www.Aeta.co

BeneitsCalendar Year Maximum $1,500, $2,500 or $3,500

per insuredLietime Deductible $100 per person/

$300 per family

* PPO i- ad out-of-etwork subject to Aeta schedule.For Aeta PPO providers please visit www.Aeta.co

REASONABLE AND CUSTOMARY

Dental expenses are paid based on a percentage of Reasonableand Customary (R&C) fees. This means the most common charge fsimilar professional services, drugs, procedures, devices, suppliesor treatment within the Geographic Area in which the charge isincurred. The most common charge means the lesser of:

the actual aout charged by the provider; the egotiated rate; the usual charge which would have bee ade by a provider

(Dentist, Hospital, etc) for the same or a comparable professionaservices, drugs, procedures, devices, supplies or treatment withi

the same Geographic Area, as determined by Us.Geographic Area means the three digit zip code in which the service,treatment, procedure, drugs or supplies are provided; or a greater areaif necessary to obtain a representative cross-section of charge for a liketreatment, service, procedure, device drug or supply.

APPLYING

Send all original forms to:

Direct Beneits, Inc.325 Cedar Street Suite 800,St. Paul MN 55101651-649-3503 / 800-620-5010651-649-3502 ax

[email protected]

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

www.directbenefits.com

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Choose Your PPO Ow Detist


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DENALI INDEMNITY MONTHLY PREMIUMS

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

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

For Aeta PPO providers, visit www.aeta.co

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InDEmnITY AnD PPO AREA FACTORS

Alabama 1Arizona 1850-851 2852-853 3Arkansas 1

Caliornia 6945-951 7Colorado 3800-804 4808-809 4Connecticut 5068-069 6Delaware 5Dist o Columbia 4Georgia 1301-302 3300, 303, 311 3

Hawaii 4Illinois 1600-608 3Iowa 2Kansas 1

Kentucky 1Louisiana 1Massachusetts 4017-019 5021-022 6Michigan 2480-485 3Minnesota 2554 4550-553, 555 3Mississippi 1

Missouri 1630-634 2640-641 2Montana 2Nebraska 1

Nevada 4893-898 5New Mexico 1North Dakota 1Ohio 1Oklahoma 1Oregon 4970-975 5Rhode Island 3South Carolina 2South Dakota 1

Tennessee 1370-372, 380-384 2Texas 1750, 751, 760 2761, 770 2

772-777, 786 2787, 789 2752-753 2Utah 3Vermont 3Virginia 1201 4220-223 3233-237 2West Virginia 1Wisconsin 2532-534, 537 3

Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8

Single $24.50 $27.52 $30.25 $32.97 $35.99 $38.72 $42.35 $48.39

Single +1 $49.01 $55.04 $60.49 $65.95 $71.98 $77.43 $84.70 $96.79

Single +2 or more $80.11 $89.98 $98.89 $107.80 $117.67 $126.58 $138.46 $158.22


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DENALI PPO MONTHLY PREMIUMS

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

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

InDEmnITY AnD PPO AREA FACTORS

Alabama 1Arizona 1850-851 2852-853 3Arkansas 1

Caliornia 6945-951 7Colorado 3800-804 4808-809 4Connecticut 5068-069 6Delaware 5Dist o Columbia 4Georgia 1301-302 3300, 303, 311 3

Hawaii 4Illinois 1600-608 3Iowa 2Kansas 1

Kentucky 1Louisiana 1Massachusetts 4017-019 5021-022 6Michigan 2480-485 3Minnesota 2554 4550-553, 555 3Mississippi 1

Missouri 1630-634 2640-641 2Montana 2Nebraska 1

Nevada 4893-898 5New Mexico 1North Dakota 1Ohio 1Oklahoma 1Oregon 4970-975 5Rhode Island 3South Carolina 2South Dakota 1

Tennessee 1370-372, 380-384 2Texas 1750, 751, 760 2761, 770 2

772-777, 786 2787, 789 2752-753 2Utah 3Vermont 3Virginia 1201 4220-223 3233-237 2West Virginia 1Wisconsin 2532-534, 537 3

For Aeta PPO providers, visit www.aeta.co

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Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8

Single $20.99 $23.38 $25.54 $27.70 $30.09 $32.24 $35.11 $39.90

Single +1 $46.18 $51.45 $56.19 $60.93 $66.20 $70.92 $77.24 $87.77

Single +2 or more $69.58 $77.51 $84.66 $91.81 $99.74 $106.86 $116.38 $132.24


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DB IN WP 0412

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

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

ELIGIBILITYDenali Dental is available to applicants aged 18 and older, their spouse and dependent children under the age of26. The primary insured must be a member of CA and all family members must be residents of the United States inorder to be covered.

COVERED CHARGES

Covered charges must be incurred while the policy is inforce and the person is covered by the policy. To becomea covered charge, the dental services must be performed by: a licensed dentist performing dental services withinthe scope of his licese; or a licesed detal hygieist actig uder the supervisio ad directio of a detist. Acovered charge is considered incurred on the following dates: for full and partial dentureson the date the finalipressio is take; for fixed bridges, crows, ilays ad olayso the date the teeth are first prepared; for rootcaal therapyo the date the pulp chaber is opeed; for periodotal surgeryo the date surgery is perfored;for all other serviceson the date the service is performed.

ALTERNATIVE BENEfITIf we determine that a less expensive alternate procedure, service or course of treatment can be performed in placeof the proposed treatment to correct a dental condition and the alternative treatment will produce a professionallysatisfactory result, then the maximum we will allow will be the charge for the less expensive treatment.

PREDETERMINATION Of BENEfITSExcept i a eergecy, before you begi treatet that will cost ore tha the predeteriatio aout show othe Certificates schedule of benefits page, your dentist must submit a claim to us describing the treatment necessaryand its cost. This estimate is not a guarantee of payment. We will still consider a claim for which you have notobtained prior approval. However, the claims will be subject to reduced benefits based on our determination ofreasonable and customary charges, and medically necessary treatment.

COORDINATION Of BENEfITSThis plan will be coordinated with any other group, blanket or franchise plan under which an individual will receivebenefits.

WAITING PERIOD TAKEOVER BENEfITSIf you were previously covered under a different dental plan with comparable coverage you may be eligible fortakeover credit under this plan at an additional cost. If your prior coverage termination date is no more than 30

days prior to the date you are requesting coverage under this plan, you are eligible for a takeover feature wherebythe length of time you were covered under your prior plan will be applied to the graded benefit features of thisplan. As a result, you will enter the plan at a higher level of benefit for coverage categories that grade up overtime.

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

PLAN INfORMATION


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The ollowing is a partial list o treatment, services or supplies, and charges that arenot covered by Denali Dental:

Treatment, services or supplies which:- Are ot edically ecessary- Are ot prescribed by a detist- Are deteried to be experietal/ ivestigatioal i ature by us

- Are received without charge or legal obligatio to pay- Would ot routiely be paid i the absece of isurace- Are received fro ay faily eber - Are ot covered procedures

Self-iflicted ijuries

War or an act or war, whether or not declared

A covered persons commission of a felony or an assault on another person

Eployet; whether caused by, related to, or as a coditio of eployet, icludig self-eployet. Thisexclusion applies even if workers compensation or any occupational disease or similar law does not cover thecharges

Congenital or development malformations existing on the covered persons effective date as shown in thecertificates schedule of benefits

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

Replacement of partial or full dentures, fixed or removable bridge work, crowns, gold restorations and jacketsore ofte tha oce i ay five-year period

Lost, stolen or missing dentures or bridges for duplicates

Charges payable under any medical insurance

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

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

Bite registrations

Bacteriologic cultures Therapeutic injections administered by a dentist

Replacement of 3rd molars

Composites on teeth posterior to the second bicuspid

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

Temporomandibular joint syndrome

NOTICE: This brochure provides a very brief description of some important features of your Plan. It is not the InsuranceContract, nor does it represent the Insurance Contract. A full explanation of benefits, exceptions and limitations iscotaied i the Certificate of Isurace uder Policy Fors mnL ADEn-POL 0905 ad SSL ADEn-POL 0905 issued toCommunicating for America.


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Payment Information

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

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

Credit Card Number: Expiration:We accept Visa, Master Card and Discover.

*Monthly or annual credit card payments available.

or

Automatic Bank WithdrawBy selecting Automatic Bank Withdrawal, Madison National Life Insurance Company of America's or StandardSecurity Life Insurance Company of New Yorks monthly premium will automatically be withdrawn from yourchecking account at the following bank.

Name on Checking Account:

Checking Account Number:

Bank (Institution) Name:

Bank Routing Number:

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

Automatic withdrawals to occur on the first of the month.

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

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

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

of my coverage.

Signature of Applicant Date

Agent Name Agent Signature Date

Direct Benefits, Inc.325 Cedar Street, Suite 800 St. Paul, MN 55101

651-649-3503 / 800-620-5010 Fax: 651-649-3502

Higher Level Dental Care


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PLEASE PRINT IN SPACE PROVIDED

LAST NAME FIRST NAME M.I. SOCIAL SECURITY #

STREET ADDRESS CITY STATE ZIP

TELEPHONE NUMBER BIRTH DATE SEX MARITAL STATUS

( ) / /

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

Dental Insurance

Self SPOUSE CHILDREN REQUESTED EFFECTIVE DATE: _____________

DEPENDENT INFORMATION

SPOUSE NAME SEX BIRTH DATE (MM-DD-YY)

MALE FEMALE / /

CHILD NAME SEX BIRTH DATE (MM-DD-YY) STUDENT (Over Age 19)

MALE FEMALE / / Yes No





WILL YOU OR ANY DEPENDENT HAVE OTHER DENTAL INSURANCE COVERAGE?_______________________

IF YES, PLEASE LIST THE NAME OF THE OTHER INSURANCE COMPANY AND PHONE NUMBER:

_____________________________________________________________________________________

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

I DECLINE DENTAL COVERAGE FOR: MYSELF MY SPOUSE MY CHILDREN

REASON FOR REFUSAL:___________________________________________________________

ACKNOWLEDGMENT AND AUTHORIZATION

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

group plan offered by Denali Dental. I reserve the right to revoke or change this authorization by written notice. I

declare all answers are true and complete.

WARNING: Any person who knowingly and with intent to defraud an insurer files an application or statement of claim

containing any false, incomplete or misleading information may be guilty of insurance fraud which is a crime.

DATE CITY AND STATE

SIGNATURE

Direct Benefits, Inc.325 Cedar Street, Suite 800 St. Paul, MN 55101

651-649-3503 / 800-620-5010 Fax: 651-649-3502


MALE FEMALE SINGLE MARRIED

MNL ADEN-MBR APP 0905

Madison National Life Insurance

Company, Inc. - P.O. Box 5008,

Madison, WisconsinIndemnity

PPO $3,500 max

$2,500 max

$1,500 max


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To expedite processing please confirm that the following is submitted.

Completed and Signed ApplicationTakeover Credit Requested

Premium Payment (Credit Card or Automatic Bank Withdrawal)

Completed and Signed Agent Information Section (when applicable)

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

Direct Benefits, Inc.325 Cedar Street, Suite 800Saint Paul, MN 55101

651.649.3503800.620.5010

651.649.3502 [email protected]

Submission Date:

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

N E W A P P L I C A T I O N C H E C K L I S T


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

Rate + $

Takeover credit (Rate x 1.20) + $

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

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

TOTAL REMITTANCE = $

325 Cedar Street, Suite 800 Sait Paul, mn 55101 ph 651.649.3503 800.620.5010 fax 651.649.3502www.directbenefits.com

Your Source for Dental, Disability, Life and Vision Benefits

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Documents

Denali Individual Dental All Other States_AETNA