Dental Services - Accidental Injury (Emergency Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.
Services to Treat an Accidental Injury This plan covers the following services to treat an accidental injury to your sound natural teeth or an injury resulting in a facial fracture, received in an emergency room or provider’s office when the treatment is received within seventy-two (72) hours of the injury. • Extraction of teeth needed to avoid infection of teeth damaged in the injury; • Suturing; • Reimplanting and stabilization of dislodged teeth; • Repositioning and stabilization of partly dislodged teeth; and • Dental x-rays.
Bodily Injury Bodily injury means death, disease, illness, physical and mental injury of or to an individual.
Work-related Injury/Disability An employee who receives an Employer Contribution and who is off the State payroll due to a work-related injury or a work-related disability remains eligible for an Employer Contribution as long as such an employee receives workers' compensation payments. If such employee ceases to receive workers' compensation payments for the injury or disability and is granted a medical leave under Article 10, he/she shall be eligible for an Employer contribution during that leave.
Accidental Damage The service contract provides protection against accidental damage to the covered product (for example: falling off Your hands, or a car, or water damage) resulting from the handling of such product and that is not intentionally caused by You. IF YOU NEED SERVICE: To locate or arrange for service, call the toll free number on the Schedule Page. We will select an Authorized Repair Center which will contact You to arrange for Your service. You should contact Us if the completion of Your repair is not satisfactory.
ACCIDENTAL DAMAGE IN HANDLING ( “ADH”): If purchased, the Covered Product is protected against accidental damage in handling such as drops and liquid spills. Immersion of Your Covered Product is not covered under this Agreement. ADH only covers operational or mechanical failure caused by a single incident while handling and does not include protection against theft, mysterious disappearance, misplacement, viruses or reckless, abusive, willful or intentional misconduct associated with handling and/or use of the Covered Product, cosmetic damage and/or other damage that does not affect the unit’s functionality, damage caused during shipment between You and Our service providers and any other limitations listed in the “What is Not Covered” section of this Agreement. For the purpose of this Agreement, Accidental Damage is defined as a single, unexpected, sudden and unintentional event and does not include accumulated damage from continual or multiple events. The use of this coverage requires an explanation of where and when the Accidental Damage occurred as well as a detailed description of the actual event. If needed, the replacement value of the Covered Product will be solely determined by the Administrator of this Agreement.
Accidental Death and Dismemberment Coverage An employee may purchase accidental death and dismemberment coverage that provides principal sum benefits in amounts ranging from five thousand dollars ($5,000) to one hundred thousand dollars ($100,000). Payment is made only for accidental bodily injury or death and may vary, depending upon the extent of dismemberment. An employee may also purchase from five thousand dollars ($5,000) to twenty-five thousand dollars ($25,000) in coverage for his/her spouse, but not in excess of the amount carried by the employee.
Illness or Injury If an employee or dependent of an employee shall, while the employee is insured, be confined in a hospital as a bed-patient for treatment and not primarily for medical investigation or diagnosis only, and if the employee shall incur expense in respect of such confinement, the Company will pay, subject to the proviso below, benefits equal to the actual charges made by the hospital for bed, board and routine nursing services as regularly provided by such hospital, but the Company will in no event make payment in respect of that part of any charge for bed, board and routine nursing services which exceeds
Accidental Death & Dismemberment The Employer agrees to continue to make payroll deductions equivalent to the premiums for the current Accidental Death and Dismemberment Insurance Plan administered by the Union. All monies so deducted shall be remitted to the Union within fifteen (15) days of the end of the month in which the deductions were made along with a list of names of employees from whom the deductions were made.
Basic Life and Accidental Death and Dismemberment Coverage The Employer agrees to provide and pay for the following term life coverage and accidental death and dismemberment coverage for all supervisors eligible for an Employer Contribution, as described in Section 3. Any premium paid by the State in excess of fifty thousand dollars ($50,000) coverage is subject to a tax liability in accord with Internal Revenue Service regulations. A supervisor may decline coverage in excess of fifty thousand dollars ($50,000) by filing a waiver in accord with Minnesota Management & Budget procedures. The basic life insurance policy will include an accelerated benefits agreement providing for payment of benefits prior to death if the insured has a terminal condition. Supervisors’ Annual Base Salary Group Life Insurance Coverage Accidental Death and Dismemberment Principal Sum $10,000 - $15,000 $15,000 $15,000 $15,001 - $20,000 $20,000 $20,000 $20,001 - $25,000 $25,000 $25,000 $25,001 - $30,000 $30,000 $30,000 $30,001 - $35,000 $35,000 $35,000 $35,001 - $40,000 $40,000 $40,000 $40,001 - $45,000 $45,000 $45,000 $45,001 - $50,000 $50,000 $50,000 $50,001 - $55,000 $55,000 $55,000 $55,001 - $60,000 $60,000 $60,000 $60,001 - $65,000 $65,000 $65,000 $65,001 - $70,000 $70,000 $70,000 $70,001 - $75,000 $75,000 $75,000 $75,001 - $80,000 $80,000 $80,000 $80,001 - $85,000 $85,000 $85,000 $85,001 - $90,000 $90,000 $90,000 Over $90,000 $95,000 $95,000
