DENTAL PLAN
HANDBOOK
P L A N Y E AR 2 0 2 3
DRAFT
4883
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Dental Plan HandbookPlan Year 2023
TABLE OF CONTENTS
Notices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
HealthChoice Plan Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . .3
HealthChoice Plan Identication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
HealthChoice Provider Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Summary of Dental Plan Benets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Claim Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
General Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Eligibility and Effective Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Continuing Coverage After Leaving Employment . . . . . . . . . . . . . . . . . . . . . 21
Termination or Reinstatement of Coverage. . . . . . . . . . . . . . . . . . . . . . . . .25
Privacy Notice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Fraud, Waste and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Plan Denitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
This dental handbook replaces and supersedes any dental handbook the Ofce of
Management and Enterprise Services Employees Group Insurance Division previously
issued. This dental handbook will, in turn, be superseded by any subsequent dental
handbook OMES issues. The most current version of this dental handbook can be
found at HealthChoiceOK.com.
NOTICES
READ THIS HANDBOOK CAREFULLY
The Ofce of Management and Enterprise Services Employees Group Insurance Division
provides dental benets to eligible state, education and local government employees, former
employees and their dependents in accordance with the provisions of 74 O.S. § 1301, et seq.
The information provided in this handbook is a summary of the benets, conditions, limitations
and exclusions of the HealthChoice Dental Plan (referenced herein as plan or plans). It should
not be considered an all-inclusive listing. All references to “you” and “your” relate to the plan
member.
● Plan benets are subject to conditions, limitations and exclusions, which are described
and located in Oklahoma statutes, handbooks and Administrative Rules adopted by the
plan administrator. You can obtain a copy of the ofcial Administrative Rules from the
Ofce of the Oklahoma Secretary of State. An unofcial copy of the rules is available
on the EGID website at Oklahoma.gov/omes. In the menu bar under Services, select
Employees Group Insurance Division. Under Resources, select About EGID, then select
Administrative Rules under Resources.
● A dispute concerning information contained within any plan handbook or any other
written materials, including any letters, bulletins, notices, other written document or oral
communication, regardless of the source, shall be resolved by a strict application of
Administrative Rules or benet administration procedures and guidelines as adopted by
the plan. Erroneous, incorrect, misleading or obsolete language contained within any
handbook, other written document or oral communication, regardless of the source, is of
no effect under any circumstance.
INFORMATION AVAILABLE ONLINE
HealthChoice website
The HealthChoice website at HealthChoiceOK.com is for existing and prospective
HealthChoice members to nd detailed information around the clock. This includes an overview
of each of the HealthChoice plans for active and Medicare members. The HealthChoice
Health, Dental, Life, Disability and Medicare Supplement Plan Handbooks are available online
where members can also search for HealthChoice network providers.
HealthChoice member portal
You can log into the HealthChoice member portal from the HealthChoice website. This online
tool is designed to give you quick and easy access to your member and dependent benet
information, temporary member ID cards, claims, account balances and more. You can also
use the member portal to nd a network provider or chat with a HealthChoice Customer Care
representative via secure message. If you haven’t already registered for the HealthChoice
member portal, you need to create a unique username and password to access your
information. Your covered dependents 18 and older must register independently for their own
access.
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Dental Plan Handbook Plan Year 2023
HEALTHCHOICE PLAN CONTACT INFORMATION
HealthChoice Customer Care
Dental benet coverage, claims, certi
cation inquiries and dental records
800-323-4314
TTY 711
HealthChoiceOK.com
Claims and correspondence
P.O. Box 30511
Salt Lake City, UT 84130-0511
Appeals and provider inquiries
P.O. Box 30546
Salt Lake City, UT 84130-0546
Pharmacy benet manager
CVS Caremark
CVS Customer Care: 877-720-9375.
TTY 711
Caremark.com
Subrogation administrator
McAfee & Taft
405-235-9621 or 800-235-9621
Two Leadership Square, 10th Floor
211 N. Robinson Ave.
Oklahoma City, OK 73102
Eligibility and enrollment
EGID Member Services
405-717-8780 or 800-752-9475
TTY 711
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Dental Plan HandbookPlan Year 2023
HEALTHCHOICE PLAN IDENTIFICATION
Plan name
HealthChoice Dental Plan
Plan administrator
Ofce of Management and Enterprise Services
Employees Group Insurance Division
405-717-8780 or 800-752-9475.
2401 N. Lincoln Blvd., Ste. 300
Oklahoma City, OK 73105
HealthChoiceOK.com.
HEALTHCHOICE PROVIDER NETWORK
You can seek care from a network or non-network provider; however, the amount you are
responsible for paying is substantially higher when you use a non-network provider. With a
statewide and multistate network of more than 1,700 dentists, oral and maxillofacial surgeons,
orthodontists and periodontists, the HealthChoice Provider Network is one of the largest in
Oklahoma.
Finding a HealthChoice network provider
You can nd a HealthChoice network provider through HealthChoiceOK.com using the
HealthChoice member portal.
You can also contact HealthChoice Customer Care and a member advocate can give you the
names of network providers in your area.
If you are unable to locate a HealthChoice network provider in your area, you can nominate a
provider for participation by completing the online provider nomination form or contacting EGID
Member Services.
Refer to HealthChoice Plan Contact Information.
Importance of selecting a HealthChoice network provider
Network providers
Network providers are contracted with HealthChoice and have agreed to accept HealthChoice
allowable amounts for the services and equipment they provide. Network providers have
agreed not to bill you for charges that are greater than allowable amounts until you exceed
your calendar year maximum benet. You are still responsible for your plan’s copays,
deductibles, coinsurance and charges for non-covered services.
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Dental Plan Handbook Plan Year 2023
Non-network providers
Non-network providers are not contracted with HealthChoice and have not agreed to accept
allowable amounts. This means you are responsible for paying the difference between the
amount the provider bills and allowable amount. This process, known as balance billing, can
be a large amount of money out of your own pocket. Even after you reach your plan’s out-of-
pocket maximum, you are still responsible for all amounts above allowable amounts when you
use non-network providers.
SUMMARY OF DENTAL PLAN BENEFITS
Network providers
When using a network provider, the plan provides the following benets:
● Preventive services covered at 100% of allowable amounts.
● A calendar year deductible of $25 per individual or $75 maximum per family of three or
more for basic and major restorative services. This is separate from the non-network
calendar year deductible and amounts accumulated do not cross-apply.
● Basic restorative services covered at 85% of allowable amounts after the deductible has
been met.
● Major restorative services covered at 60% of allowable amounts after the deductible has
been met.
● Orthodontic services for members under 19, or members 19 and older with
temporomandibular joint dysfunction, are covered at 50% of allowable amounts. There
is no calendar year deductible or lifetime maximum benet; however, a 12-month
waiting period applies to all orthodontic benets except for those members being treated
for TMJ/TMD. Refer to Limitations in the Exclusions and Limitations section.
● Network providers le your claims for you.
Non-network providers
When using a non-network provider, the plan provides the following benets:
● Preventive services covered at 100% of allowable amounts after the deductible has
been met.
● A calendar year deductible of $25 per individual or $75 maximum per family of three
or more for preventive, basic and major services. This is separate from the network
calendar year deductible and amounts accumulated do not cross-apply.
● Basic restorative services covered at 70% of allowable amounts after the deductible has
been met.
● Major restorative services covered at 50% of allowable amounts after the deductible has
been met.
● Orthodontic services for members under 19 or members 19 and older with TMJ/TMD
are covered at 50% of allowable amounts. There is no calendar year deductible or
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Dental Plan HandbookPlan Year 2023
lifetime maximum benet; however, a 12-month waiting period applies to all orthodontic
benets except for those members who are being treated for TMJ/TMD. Refer to
Limitations in the Exclusions and Limitations section.
Note: If you use a non-network provider, you must le your claims yourself unless the provider
is willing to le for you as a courtesy. Refer to Claim Procedures.
The calendar year maximum benet per person for network and non-network preventive, basic
and major services combined is $2,500. The calendar year maximum benet does not apply to
orthodontic services.
You are responsible for all non-covered services, amounts above the calendar year maximum
benet, and amounts above allowable amounts when using non-network providers.
Schedule of covered benets
Network Non-network
Covered services
Calendar
year
deductible
Plan pays
(of allowable
amounts)
Calendar
year
deductible
Plan pays
(of allowable
amounts)
Preventive
None 100%
$25/$75**
100%
Basic restorative
$25/$75*
85% 70%
Major restorative
60% 50%
Orthodontic
None 50% None 50%
*Network services: There is a calendar year deductible of $25 per individual or $75 maximum
per family of three or more for basic and major services combined.
**Non-network services: There is a calendar year deductible of $25 per individual or $75
maximum per family of three or more for preventive, basic and major services combined.
Note: Network and non-network deductibles accumulate separately.
Maximum benets
The calendar year maximum benet per person for network and non-network preventive, basic
and major services combined is $2,500. The calendar year maximum benet does not apply to
orthodontic services.
Once you exhaust your $2,500 calendar year maximum benet, your provider is not limited to
the HealthChoice allowable amounts. You are responsible for all amounts above the calendar
year maximum benet.
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Dental Plan Handbook Plan Year 2023
Preventive services
Covered services include:
● Cleaning, bitewing X-rays, routine oral examinations; two covered per calendar year.
● Topical uoride treatments; two covered per calendar year.
● Full mouth X-rays; one covered per 36 months.
● Supplemental bitewing X-rays; two covered per calendar year.
● Space maintainers to replace prematurely lost teeth for covered dependent children
under 19.
● Emergency palliative treatment.
● Sealants, only on molars; reapplication once every 36 months.
● Preventive resin restorations in moderate-to-high-risk caries patients, only on molars, no
age restriction; reapplication every 60 months.
Basic restorative services
Covered services include:
● Extractions, including wisdom teeth.
● Oral surgeries, including general anesthesia.
● Amalgam, silicate, acrylic, synthetic porcelain and composite lling restorations to
restore diseased or fractured teeth.
● Certain treatments for periodontal disease.
● Endodontic treatments, root canal therapies and injections of antibiotic medications.
● Repair or recementing of bridges, crowns, inlays, onlays or dentures.
● Relining or rebasing of dentures once every three years, except during the rst six
months after the initial installation or replacement of the denture.
Major restorative services
Covered services include:
● Initial placement of full or partial removable dentures, xed bridgework, replacement
of existing partials, or an addition of teeth to partial removable dentures or bridgework
as covered by the plan. The existing dentures or bridgework must have been installed
at least ve years prior to its replacement and cannot be repairable, or the existing
dentures must be immediate temporary dentures that cannot be made permanent.
Replacement with permanent dentures must take place within 12 months of the initial
installation of the temporary dentures.
● Dental implant systems approved by the Food and Drug Administration.
● Inlays, onlays, gold llings or crown restorations to restore diseased or fractured teeth,
but only when the teeth, as a result of extensive cavities or fractures, cannot be restored
to proper function with amalgam, silicate, acrylic, synthetic porcelain or composite
restorations.
Note: HealthChoice does not have a missing tooth clause.
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Dental Plan HandbookPlan Year 2023
Orthodontic services
Covered services include:
● Orthodontic services for members under 19.
● Orthodontic services for treatment of TMJ/TMD for members at any age.*
● Molar uprighting.
There is no calendar year deductible or lifetime maximum benet for network or non-network
orthodontic services.
A 12-month orthodontic waiting period applies to all orthodontic benets except for those
members who are being treated for TMJ/TMD. Refer to Limitations in the Exclusions and
Limitations section.
Overpayments are assessed for orthodontic banding if the member terminates HealthChoice
dental coverage prior to the standard 24 months (or specic treatment time) of orthodontic
treatment. These overpayments may be the member’s responsibility.
There is no calendar year or lifetime maximum benet for orthodontic services.
*Certication is required for specic orthodontic services. Providers must submit certication
requests to HealthChoice Customer Care for certication review.
EXCLUSIONS AND LIMITATIONS
Exclusions
There is no coverage for the items listed below:
1. Dental care and supplies furnished in a facility operated under the direction of, or at the
expense of, the U.S. government, or its agency or by a provider employed by such a
facility.
2. Dental care and supplies for which there is no charge made or no payment is required if
the insured individual does not have coverage.
3. Dental care and supplies provided by a denturist.
4. Dental care and supplies that result from committing or attempting to commit an assault
or felony.
5. Dental care and supplies due to sickness or injury covered by workers’ compensation,
occupational disease law or similar laws.
6. Dental care and supplies to the extent that they are payable under other provisions of
the policy.
7. Direct-to-consumer orthodontic treatment.
8. Charges incurred after the covered individual’s benet ends.
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Dental Plan Handbook Plan Year 2023
9. Supplies and prescription drugs for dental care or treatment, other than those used in a
dentist’s ofce, or instructions in dental hygiene. Prescription drugs prescribed by your
dentist may be covered by your health plan.
10. Intentionally self-inicted injury or illness, except when the injury (a) resulted from being
the victim of an act of domestic violence or (b) resulted from a documented medical
condition that is covered under the HealthChoice Dental Plan.
11. Hospital connement and ancillary services, including anesthesia for dental surgery,
when the connement is necessary due to illness or other health conditions. These
charges should be led with your health plan.
12. Replacement of lost dentures.
13. Separately billed infection control amounts.
14. Charges for missed or canceled appointments.
15. Gel-Kam and other take-home uorides.
16. Oral care and supplies used to change vertical dimension or closure, except as provided
under orthodontic benets.
17. Adult orthodontics without a diagnosis of TMJ/TMD.
18. Medical expenses for the treatment of TMJ/TMD.
19. Cosmetic procedures.
20. Charges made by a duly qualied dentist or oral surgeon for treatment of fractures and
dislocations of the jaw, or for cutting procedures and treatment. These charges may be
covered by your health plan.
21. Medical services treating an oral condition.
22. Services supplied by a provider who is a relative of the patient, by blood or by marriage,
or one who normally lives in the patient’s home.
23. Separately billed local or block anesthesia used in conjunction with restorative or
surgical procedures.
24. Charges for injuries resulting from war or act of war (whether declared or undeclared)
while serving in the military or an auxiliary unit attached to the military or working in an
area of war whether voluntarily or as required by an employer.
This list is not all-inclusive.
Limitations
Orthodontic waiting period
No orthodontic benets are available to members or dependents during the rst 12 consecutive
months of coverage. This 12-month waiting period does not apply to the treatment of TMJ/
TMD.
Benets for orthodontic services received during the waiting period are prorated once 12
consecutive months of coverage are completed.
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Dental Plan HandbookPlan Year 2023
Dental accidents
Dental accidents are covered under the HealthChoice health plans, which pay for medically
necessary treatment for the repair of injury to sound natural teeth or gums. You must be a
member of a HealthChoice health plan, and treatment must be performed within 12 months
following the accident. If you are enrolled in a different health plan, contact that plan for
information on how dental accidents are covered.
CLAIM PROCEDURES
Claim ling and payment
Dental claims must be submitted on the most current American Dental Association claim form.
Items such as cash register receipts, pull-apart forms and billing statements are not accepted.
Network
Network providers le your claims for you and payment is automatically made to your provider.
Non-network
Non-network providers are not required to submit claims on your behalf and may not use the
appropriate form. If this is the case, ask if they can submit the claim on your behalf using the
appropriate form or if they can provide you a completed form so you can le the claim yourself.
Claims should be led as soon as services are received or completed. Send your claim to
HealthChoice Customer Care. Refer to HealthChoice Plan Contact Information.
Non-network claims are usually paid to you; however, you can choose to assign benets
directly to your provider.
When a valid assignment of benets to your provider is submitted with your claim, payment is
made to your provider.
When there is no valid assignment of benets, payment is made to you and you are
responsible for paying your provider.
Claims ling deadline
Claims must be submitted within 180 days from the date of service.
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Dental Plan Handbook Plan Year 2023
Claims for services outside the United States
If you receive dental care outside the United States, follow these claim procedures for
reimbursement:
● Arrange to pay for the services or supplies.
● Have claims translated into English before you le your claim. The plan does not pay
any costs for translating claims or dental records.
● Convert charges to U.S. dollars using the exchange rates for the dates of service.
● Submit a member self-submission dental claim form.
● Submit the original claim along with the translation.
● Contact HealthChoice Customer Care for assistance. Refer to HealthChoice Plan
Contact Information.
Submit the claim form, translation and itemized statement to:
HealthChoice
P.O. Box 30511
Salt Lake City, UT 84130-0511
Allowable amounts are paid at the non-network rate of coinsurance. You are responsible for
amounts above the allowable amounts.
Coordination of benets
You are required to annually verify if you or any of your covered dependents have other
group dental insurance coverage. You should also notify us anytime you or your covered
dependent(s) adds or drops other dental insurance. You may complete your verication
through the HealthChoice member portal at HealthChoiceOK.com or by calling HealthChoice
Customer Care at 800-323-4314. This process establishes which insurance plan is primary
when two plans must work together to pay claims for the same person. Coordinating benets
ensures that the two plans do not pay more than the total amount of the claim, thereby helping
to reduce the cost of insurance premiums.
If you have questions about how your pharmacy benets will be affected by coordination
of benets, contact the pharmacy benet manager. Refer to HealthChoice Plan Contact
Information.
Failure to verify other insurance coverage may result in denial of claims until
verication is completed.
Explanation of benets
Each time a claim is processed, HealthChoice Customer Care creates an explanation of
benets that explains how your benets are applied. Your EOB includes:
● Amount allowed.
● Amount not covered.
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Dental Plan HandbookPlan Year 2023
● Coinsurance.
● Copay.
● Date of service.
● Deductible.
● Explanation code.
● Provider write-off.
● Provider.
● Total benets.
● Total billed amount.
Your EOBs are available through the HealthChoice member portal at HealthChoiceOK.com. If
you have difculty accessing your EOB online, contact HealthChoice Customer Care. Refer to
HealthChoice Plan Contact Information.
Claims requiring additional information
If your dental claim requires additional information for processing, your EOB identies the
specic information needed. In some instances, a letter is also sent that explains what
information is required to complete claim processing. Your claim is closed until this information
is received.
Please be sure to include your member ID number and claim number when returning the
requested information. Once the information is provided to HealthChoice Customer Care, your
claim is automatically processed. You do not need to resubmit your claim.
Pre-estimate
If your dental treatment is expected to cost more than $500 for preventive, basic or major
services, a pre-estimate of dental benets is recommended. A pre-estimate is led like a claim
and provides you with an overview of the costs of your treatment and the amounts the plan
will pay. A pre-estimate should be submitted before treatment begins and include required
supporting documentation.
Your dentist or specialist must bill for the exact services pre-estimated unless you make a
request for additional services.
Disputed claims procedure
If your claim is denied in whole or in part for any reason, either you or your authorized
representative can request the claim be reviewed. Log in at HealthChoiceOK.com and
complete the online appeal submission form, or submit a written request within 180 days of
your receipt of a denial to:
HealthChoice Appeals Unit
P.O. Box 30546
Salt Lake City, UT 84130-0546
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Dental Plan Handbook Plan Year 2023
Please follow the steps below when submitting a written request to make sure that your appeal
at any level is processed in a timely manner:
● If applicable, send a copy of any letter regarding a decision of your appeal.
● Send a copy of the EOB with any relevant additional information (e.g., benet
documents, medical records) that could help to determine if your claim is covered under
the plan.
● Provide a letter summarizing the request for reconsideration that includes your name,
the claim or transaction numbers, HealthChoice member ID number, the name of the
patient and their relationship to member.
● Include Attention: Appeals Unit on all supporting documents. Be certain the member
ID appears on each document.
● If you choose to designate an authorized representative, you must provide this
designation to us in writing.
● If your situation is medically urgent, you may request an expedited appeal, which is
generally be conducted within 72 hours. If you believe your situation is urgent, follow the
instructions above for ling an internal appeal and call HealthChoice Customer Care to
request a simultaneous external review.
Your HealthChoice plan’s internal appeals process includes two internal review levels. If you
are not satised with the nal internal review determination due to denial of payment, coverage
or service requested, you may be able to ask for an independent, external review of our
decision by either an independent review organization or a grievance panel.
The entity that performs the external review depends on the nature of your appeal.
When considering complaints by insured members, the three-member grievance panel shall
determine by a preponderance of the evidence whether EGID has followed its statutes, rules,
plan documents, policies and internal procedures. The grievance panel shall not expand upon
or override any EGID statutes, rules, plan documents, policies and internal procedures.
To request access to and copies of all documents, records and other information about your
claim, free of charge, or to nd out how to start an external review, contact HealthChoice
Customer Care.
Subrogation
Subrogation is the process through which HealthChoice has the right to recover any benet
payments made to you or your dependents by a third party’s insurer because of an injury or
illness caused by the third party. Third party means another person or organization.
Subrogation applies when you are sick or injured as a result of the negligent act or omission of
another person or party. If you or your covered dependents receive HealthChoice benets and
have a right to recover damages, this plan has the right to recover any benets paid on your
behalf. All payments from a third party, whether by lawsuit, settlement or otherwise, must be
used to repay HealthChoice.
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Dental Plan HandbookPlan Year 2023
If you are asked to provide information about the injury or accident to the HealthChoice
subrogation administrator at the law rm of McAfee & Taft, any related claims are pended until
you have supplied the necessary information. Failure to provide the required information in a
timely manner may result in your claim being denied.
Refer to HealthChoice Plan Contact Information.
GENERAL PROVISIONS
Provider-patient relationship
You can choose any provider or practitioner who is licensed or certied under the laws of the
state in which they practice and who is recognized by the plan. Each provider offering dental
care services is an independent contractor. Providers retain the provider-patient relationship
with you and are solely responsible to you for any dental advice and treatment or subsequent
liability resulting from that advice or treatment.
Although a provider recommends or prescribes a service or supply, this does not necessarily
mean it is covered by the plan.
For information on the types of providers recognized by the plan, contact HealthChoice
Customer Care. You can also search the HealthChoice Network Provider Directory by going to
HealthChoiceOK.com.
Intentional misrepresentation
Coverage obtained by means of intentional misrepresentation of material fact is canceled
retroactive to the effective date, and premiums you paid for coverage are refunded. Refunded
premiums are reduced by any claims paid by HealthChoice.
Conrmation statements and corrections to benet
elections
When a change is made to your coverage, you are mailed a conrmation statement, which lists
your coverage and the effective date and premium amount for your coverage. It is provided so
you can review changes and identify errors as soon as possible.
If you nd errors to your benet elections, you should submit corrections within 60 days.
Current employees must submit corrections to their insurance/benets coordinator and former
employees must submit corrections directly to EGID. Corrections reported after 60 days are
effective on the rst day of the month following notication.
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Dental Plan Handbook Plan Year 2023
Member audit program
Despite your provider’s best efforts, the complexity of arranging for your care and treatment
may result in inaccurate billing, so it is important to check your bill carefully. If you discover
certain mistakes in your bill, you can share in the savings through the Member Audit Program.
You can receive up to 50% of any savings resulting from a billing error you nd, limited to a
maximum reimbursement of $200 per incident or $500 per year, per member or family. Please
note that the error must have impacted the actual benet amount paid by at least $50.
Eligible errors include charges for services not provided or charges that are billed incorrectly.
Billing mistakes such as transposed numbers, addition mistakes and misplaced decimals are
not eligible for the program. Only charges for services covered by the plan are eligible.
If you nd an error on a dental bill and you wish to participate in the Member Audit Program,
complete the Member Audit Program Form found at HealthChoiceOK.com and return to the
address below. You must report the billing error prior to detection and correction by
the claims administrator to qualify. If you have any questions regarding the Member Audit
Program, call the EGID HealthChoice Fraud, Waste and Abuse toll-free hotline at 866-381-
3815, email [email protected], or fax 405-717-8922.
EGID HealthChoice Program Integrity Unit
2401 N. Lincoln Blvd., Ste. 300
Oklahoma City, OK 73105
Right of recovery
HealthChoice retains the right to recover any payments made by the plan in excess of the
maximum allowable amounts. HealthChoice has the right to recover such payments, to the
extent of excess, from one or more of the following:
● Any persons to, for or with respect to whom such payments were made.
● Any other insurers.
● Service plans or any other organizations.
ELIGIBILITY AND EFFECTIVE DATES
You are eligible to participate in the HealthChoice Dental Plan if you are:
● A current education employee eligible to participate in the Oklahoma Teachers’
Retirement System and working a minimum of four hours per day or 20 hours per week.
● A current State of Oklahoma, local government or certain nonprot employee
regularly scheduled to work at least 1,000 hours a year and not classied as a
temporary or seasonal employee.
● A person elected by popular vote (e.g., board members for education and elected
ofcials of state and local government, , rural water district board members and county
election board secretaries.
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Dental Plan HandbookPlan Year 2023
New employee
As a new employee, your coverage is effective on the rst day of the month following your
employment date or the date you become eligible with your employer. If you want to make
changes to the coverage you initially elected, you have a 30-day window following your
eligibility date to make benet changes. These changes are effective on the rst day of the
month following the date the changes are made.
Note: No orthodontic benets are available to members and dependents during the rst 12
consecutive months of coverage. This does not include orthodontic services for TMJ/TMD if
the member is 19 or older. Refer to Limitations in the Exclusions and Limitations section.
Dependent coverage
You must be enrolled in a group health plan or other qualied health insurance to enroll
yourself and your dependents in the HealthChoice Dental Plan. If dependent coverage is
elected, all your eligible dependents must be covered. Refer to Excluding dependents from
coverage in this section for exceptions to this rule.
If you are enrolled and have a new dependent as a result of marriage, birth, adoption or
placement for adoption, you can enroll your dependent provided you request enrollment within
30 days following the marriage, birth, adoption or placement for adoption. All other enrollments
must be made during the annual Option Period and some limitations may apply. Refer to the
Exclusions and Limitations section.
Note: Former employees can make changes only within 30 days of a qualifying event.
Dependents or new benet plans, other than vision, cannot be added during the annual Option
Period.
If your spouse is also a primary member of the HealthChoice Dental Plan through their
employer, dependent children can be covered under either parent’s dental plan, provided the
parent is also enrolled. Dependent children cannot be covered under both parents’ dental
plans.
Eligible dependents
Eligible dependents include:
● Your legal spouse (refer to the paragraph on common-law marriages in this section).
● Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child or child
legally placed with you for adoption up to age 26, whether married or unmarried.
Note: Plan coverage that terminates upon the dependent’s 26th birthday will terminate
at the end of the month in which the birthday occurs.
● Your dependent, regardless of age, who is incapable of self-support due to a disability
diagnosed prior to age 26. A Disabled Dependent Assessment form must be submitted
at least 30 days prior to the dependent’s 26th birthday. The form must be approved by
EGID before coverage begins or is extended beyond age 26.
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Dental Plan Handbook Plan Year 2023
● Other unmarried children up to age 26 who live with you and for whom you are primarily
responsible. This requires completion of an acceptable Application for Coverage for
Other Dependent Children. A tax return showing dependency can be provided in lieu of
the application.
Common-law marriages are recognized by the plan. A new employee can add a common-law
spouse at the time of enrollment. A current employee can request coverage on a common-
law spouse during the annual Option Period or in the event the common-law spouse loses
other group coverage. To enroll a common-law spouse, the employee and spouse must sign
and submit an enrollment or change form. Note: A former employee can add a common-law
spouse only if the common-law spouse loses other group dental coverage.
Adding a newborn to coverage:
● Newborns must be added on the rst day of the month of the child’s birth. You have 30
days from the date of birth to enroll a newborn in coverage. An Insurance Change Form
must be completed and submitted to your insurance/benets coordinator or EGID.
● Premiums must be paid for the full month of the child’s birth.
● When one or more eligible dependents are currently covered, a newborn must be added
to the same coverage, unless there is proof of other dental coverage.
● When a newborn is added to coverage, all other eligible dependents must be enrolled
in coverage if they are not already enrolled; however, you can elect to exclude your
spouse from dental coverage.
● You can request coverage for a newborn grandchild by completing an Application
for Coverage for Other Dependent Children. Coverage for a newborn grandchild is
retroactive to the rst day of the month of birth following the receipt and approval of an
application and payment of premiums. After 30 days, a retired member cannot add a
newborn to coverage without a qualifying event.
● A Social Security number for the newborn is not required at the time of initial enrollment
but must be provided when it is received from the Social Security Administration.
Current employees must provide the number to their insurance/benets coordinator.
Former employees must provide it to EGID.
Coverage for other eligible dependents
When you have not been granted custody, adoption or guardianship by a court and the
dependent is not your natural child or stepchild, you can request coverage for other unmarried
dependents up to age 26 by submitting an enrollment or change form and a copy of the
portion of your most recent income tax return listing the children as dependents for income tax
deduction purposes. Current employees must submit the form and tax return to their insurance/
benets coordinator, and former employees must submit these documents to EGID.
In the absence of a federal income tax return listing the children as dependents, you must
provide and have an approved Application for Coverage for Other Dependent Children as
specied by the plan.
Coverage for other eligible dependents begins on the rst day of the month following the date
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Dental Plan HandbookPlan Year 2023
you obtain physical custody or date the Application for Coverage for Other Dependent Children
is approved and never applies retroactively, except in the case of a newborn. Coverage for a
newborn is effective on the rst day of the month of birth.
You must request coverage within 30 days of the date of initial placement, otherwise:
● Current employees and COBRA members cannot add dependents to coverage until the
next annual Option Period.
● Former employees cannot add dependents to coverage without a qualifying event.
Note: You must meet all eligibility requirements, cover all eligible dependents and pay all
premiums.
The plan has the right to verify the dependent status of children, request copies of the portion
of your most recent income tax return listing the children as dependents and discontinue
coverage for dependents who are deemed ineligible for coverage.
Legal adoption
An adopted dependent is eligible for coverage on the rst day of the month you obtain physical
custody of your child. You must submit an enrollment or change form, including a copy of your
adoption papers. Current employees must submit the paperwork to their insurance/benets
coordinator and former employees must submit their paperwork directly to EGID. In the
absence of adoption papers or other court records, someone involved in the adoption process
such as your attorney or a representative of the adoption agency must provide proof of the
date you received custody of your child pending the nal adoption hearing.
You must request coverage within 30 days of the date of the initial placement for adoption,
otherwise:
● Current employees and COBRA members cannot add dependents to coverage until the
next annual Option Period.
● Former employees cannot add dependents to coverage without a qualifying event.
Legal guardianship
Legal guardianship follows the same guidelines as an adoption. Refer to Legal adoption in this
section.
Excluding dependents from coverage
Any of your eligible dependents can be excluded from coverage if they have other group
coverage or are eligible for Indian Health Services or military benets. You can exclude your
eligible dependent children who do not reside with you, are married or are not nancially
dependent on you for support.
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Dental Plan Handbook Plan Year 2023
You can also exclude your spouse from dental coverage. If you exclude your spouse and cover
other eligible dependents, your spouse must sign the Spouse Exclusion Certication section of
your enrollment or change form.
Changes to coverage after initial enrollment
If you declined enrollment in the HealthChoice Dental Plan because you had other group
dental insurance coverage or Indian Health Services or military dental benets, you can enroll:
● Within 30 days of the date that you lose other group dental coverage.
● During the annual Option Period.
Certain qualifying events allow a midyear benet change; however, an enrollment or change
form must be completed within 30 days of the qualifying event. Examples of midyear qualifying
events include:
● A change in your legal marital status, such as marriage, divorce or death of your
spouse.
● A change in the number of your dependents, such as the birth of a child.
● A change in employment status that affects your eligibility or that of your spouse or
dependent.
● An event that causes your dependent to meet, or fail to meet, eligibility requirements.
● Commencement or termination of adoption proceedings.
● Judgments, decrees or orders (your employer may allow changes only to health and
dental).
● Medicare eligibility for you or a dependent.
● Medicaid eligibility for you or a dependent; only two changes are allowed per plan year,
once out and once back in or vice-versa.
● Changes in the coverage of your spouse or dependent under another employer’s plan.
● Eligibility for leave under the Family Medical Leave Act.
● The Uniformed Services Employment and Reemployment Rights Act of 1994.
To request special enrollment or obtain more information, current employees contact your
insurance/benets coordinator. Former employees contact EGID Member Services. Refer to
HealthChoice Plan Contact Information.
Current employees
You can make changes to coverage only within 30 days of a qualifying event or during the
annual Option Period.
All changes to coverage must comply with the rules of your employer’s Section 125 plan, or if
no 125 plan is offered, in compliance with allowed midyear coverage changes as dened by
Title 26, Section 125, of the Internal Revenue Codes (as amended) and pertinent regulations.
Current employees must contact their insurance/benets coordinator and complete an
enrollment or change.
Note: Due to Section 125 considerations, all state agencies are part of the same employer.
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Dental Plan HandbookPlan Year 2023
Former employees and surviving dependents
The only time you can make changes to your existing dental coverage is within 30 days of a
qualifying event. For example, dependents can be added to your existing dental coverage if
a qualifying event occurs, but they cannot be added at the annual Option Period. In addition,
no new benet plans, other than vision, can be added at the annual Option Period after
retirement.
Former employees and surviving dependents must submit a written request for changes in
coverage to:
EGID
P.O. Box 11137
Oklahoma City, OK 73136-9998
Requests for changes can also be faxed to 405-717-8939. Verbal requests for changes in
coverage are not accepted.
Note: Oklahoma law prohibits dropping your spouse/dependents if you are in the process of
a divorce or legal separation at any time. If you are in the process of separation or divorce, it
is important that you contact your legal counsel for advice before making any changes to your
coverage.
Options for current employees called to active military
service
Under the Uniform Services Employment and Reemployment Rights Act of 1994, coverage
can be continued for up to 24 months. USERRA provides certain rights and protections for all
employees called to serve our nation. All branches of the military, all military reserve units and
all National Guard units come under USERRA.
In addition to health care provided by the military, you have the following four choices
regarding your current coverage:
● Retain all coverage. Your current employer is responsible for collecting and forwarding
all premiums to EGID.
● Discontinue member coverage but retain dependent coverage. This is the COBRA
option and dependents are billed directly at 102% of premiums, the COBRA rate, for
health, dental and vision coverage. Under COBRA rules, life insurance cannot be
retained.
● Discontinue all coverage except life insurance. You are billed directly.
● Discontinue all member and dependent coverage.
Each month, you must pay the full premium for the coverage you selected. Failure to pay
premiums timely can result in the termination of coverage at the end of the month for which the
last full premium was received. There is no penalty for renewing coverage upon discharge from
active duty if coverage is elected within 30 days of your return to the same employment.
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Dental Plan Handbook Plan Year 2023
Regardless of whether you receive written or verbal military orders, EGID staff and your
insurance/benets coordinator will assist you in making any benet arrangements. If you are
a member of a military reserve unit or the National Guard and anticipate being called to active
service, notify your insurance/benets coordinator at work.
Leave without pay – current employees
If you are on approved leave without pay through your employer, you can continue coverage
for up to 24 months from the day you begin leave without pay status. You must make timely
premium payments in full each month to your insurance/benets coordinator.
If your coverage terminates for failure to pay premiums on time, you can re-enroll upon
returning to work.
If you take leave under the Family Medical Leave Act, please make premium payment
arrangements with your employer before you take leave.
CONTINUING COVERAGE AFTER LEAVING
EMPLOYMENT
If you leave employment, you and/or your eligible dependents may be able to begin or continue
coverage through one of the following options.
● Vesting or retirement rights through a state-funded retirement system established by the
State of Oklahoma.
● Years of service with state, education or local government employers; refer to years of
service in this section.
● Receiving benets through the HealthChoice Disability Plan administered by EGID.
● Survivor Rights for your covered dependents in the event of your death.
● COBRA.
Each month, premiums must be paid in full. Failure to pay premiums on time can result in the
termination of coverage at the end of the month for which the last premium was received.
Years of service
You can begin or continue coverage after leaving employment if you make an election within
30 days following your employment termination date, and you meet one of the following
conditions:
● You are eligible to participate in the Oklahoma Public Employees Retirement System
and have eight or more years of service with a participating employer.
● You are eligible to participate in the Oklahoma Pathnder Plan and have ve or more
years of service.
● You are an employee of a local government employer that participates in the plan but
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Dental Plan HandbookPlan Year 2023
does not participate in the Oklahoma Public Employees Retirement System and have
eight or more years of creditable service.
● You are eligible to participate in the Oklahoma Teachers’ Retirement System and have
10 or more years of service with a participating employer.
● You are an employee of an education employer that participates in the plan but does not
participate in the Oklahoma Teachers’ Retirement System and have 10 or more years
of creditable service. Documented conrmation should be submitted to EGID from the
employer.
Education employees
If you were a career tech employee or a common school employee who terminated active
employment on or after May 1, 1993, you can continue coverage through the plan if the school
system from which you retired or vested continues to participate in the plan. If your former
school system terminates coverage under the plan, you must follow your former employer to its
new insurance carrier.
If you were an employee of an education entity other than a common school (e.g., higher
education, charter school), you can continue coverage through the plan if the education entity
from which you retired or vested continues to participate in the plan. If your former employer
terminates coverage with the plan, you must follow your former employer to its new insurance
carrier.
Note: You cannot reinstate coverage that you discontinue or allow to lapse unless you return
to work as an employee of a participating employer. Refer to Reinstatement in the Termination
or Reinstatement of Coverage section.
Local government employees
If you were a local government employee who terminated active employment on or after Jan.
1, 2002, you can continue coverage through the plan if the employer from which you retired or
vested continues to participate in the plan. If your former employer terminates coverage with
the plan, you must follow your former employer to its new insurance carrier.
Note: You cannot reinstate coverage you discontinue or allow to lapse unless you return to
work as an employee of a participating employer. Refer to Reinstatement in the Termination or
Reinstatement of Coverage section.
Some reinstatement exceptions may apply if you are a state employee who terminated
employment as a result of a reduction in force. Refer to State Government Reduction in Force
and Severance Benets Act in the Termination or Reinstatement of Coverage section.
New employer retirees
All retirees with former employers that joined the plan after the specied grandfathered dates
must follow their former employer to its new insurance carrier.
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Dental Plan Handbook Plan Year 2023
Following your employer to a new carrier
When you terminate employment, your benets are tied to your most recent employer. If your
employer discontinues participation with EGID, some or all the employer’s retirees and their
dependents (depending on the type of employer) must follow the employer to its new insurance
carrier. This is true regardless of the amount of time you were employed with any participating
employer.
If you retire and then return to work for another employer and enroll in benets through your
new employer, your benets are tied to your new employer.
Continuation through the Disability Plan
You can keep dental coverage in effect if you are receiving benets through the HealthChoice
Disability Plan. You can continue coverage if you are covered under the HealthChoice
Disability Plan and pay premiums on time. You must maintain continuous coverage. If you
discontinue coverage or allow coverage to lapse, it cannot be reinstated unless you return to
work as an employee of a participating employer. Refer to Reinstatement in the Termination or
Reinstatement of Coverage section.
Survivor rights
Your surviving spouse and dependents have 60 days following your death to notify EGID that
they wish to continue coverage. Coverage is effective on the rst day of the month following
your death.
● Your surviving spouse is eligible to continue insurance coverage indenitely if premiums
are paid.
● Surviving dependent children are eligible to continue coverage until age 26 if premiums
are paid.
● Disabled dependent children are eligible to continue coverage if they continue to meet
the HealthChoice denition of a disabled dependent and premiums are paid.
Note: COBRA continuation of coverage is available for dependent children who lose eligibility.
COBRA
If your or your dependent’s coverage is terminated for any of the reasons listed below,
each covered member has the right to elect temporary continuation of coverage under the
Consolidated Omnibus Budget Reconciliation Act.
You are eligible to continue coverage for up to 18 months if you lose coverage due to:
● A reduction in your hours of employment.
● Termination of your employment for reasons other than gross misconduct.
Your covered spouse is eligible to continue coverage if coverage is lost due to:
● Your death (refer to Survivor rights in this section).
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Dental Plan HandbookPlan Year 2023
● Termination of your employment for reasons other than gross misconduct.
● A reduction in your hours of employment resulting in loss of coverage.
● A divorce or legal separation.*
Your covered dependent children are eligible to continue coverage if coverage is lost due to:
● Your death (refer to Survivor rights in this section).
● Termination of your employment for reasons other than gross misconduct.
● A reduction in your hours of employment resulting in loss of coverage.
● A divorce or legal separation of the parents.*
● Your dependent no longer meets the requirements for dependent status.
*Oklahoma law prohibits dropping your spouse/dependents if you are in the process of a
divorce or legal separation at any time. It is important you contact your legal counsel for
advice before attempting to make changes to your coverage.
If you are a current employee, it is your responsibility to notify your employer within 30 days
of a divorce, legal separation or your child’s loss of dependent status under this plan.
If you are a former employee, you must notify EGID in writing within 30 days of a divorce,
legal separation or your child’s loss of dependent status under this plan.
You and/or your eligible dependents must elect continuation of coverage within 60 days after
the later of the following events occur:
● The date the qualifying event would cause you and/or your dependents to lose
coverage.
● The date your employer noties you and/or your dependents of continuation of coverage
rights.
If the qualifying event is related to termination of employment or reduced hours, coverage
can be continued for a maximum of 18 months. If the qualifying event is for any other eligible
reason, coverage for dependents can be continued for a maximum of 36 months. Continuation
of coverage terminates immediately for you and/or all covered dependents under the following
circumstances:
● The plan ceases to provide coverage.
● Premiums are not paid on time.
● You and/or your dependents become covered under another group dental plan.
If you have questions regarding COBRA, contact your insurance/benets coordinator or
EGID.
If you continue coverage under COBRA, an extension of the maximum period of coverage
may be available if a qualied beneciary is disabled or a second qualifying event occurs. You
must notify EGID of a disability or second qualifying event in order to extend the coverage
continuation period. Failure to provide timely notice of a disability or second qualifying event
can affect your right to extend the coverage continuation period.
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Dental Plan Handbook Plan Year 2023
TERMINATION OR REINSTATEMENT OF COVERAGE
Termination
Your coverage, as well as any dependent coverage, ends on the last day of the month when
one or more of the following events occur:
● You terminate employment with a participating employer and do not continue coverage
through vesting, non-vesting, retirement, disability or COBRA.
● You do not pay premiums.
● The plan is terminated.
● Your death occurs.
In addition, a dependent’s coverage ends on the last day of the month they cease to be an
eligible dependent. Upon review by EGID, if you or your dependent is found to be ineligible,
coverage is terminated effective on the rst day of the month of discovery. EGID reserves the
right to recover any benets paid on behalf of an ineligible member.
Reinstatement
If you are currently employed by a participating employer and discontinue coverage on yourself
or your dependents, you cannot apply for reinstatement of coverage until the next annual
Option Period, the loss of other group dental coverage or another qualifying event.
To reinstate dental coverage, proof of the loss of other group dental coverage or other
qualifying event must be submitted.
Former retired employees who did not continue coverage upon leaving active employment or
who later discontinued coverage must return to work with a participating employer for three
years to be eligible to add or continue that coverage when they re-retire.
Loss of coverage while under treatment
If you or your covered dependents lose dental coverage while undergoing treatment, the plan
continues to provide benets for two months following termination of coverage. The plan pays
the allowable amounts in the following situations according to plan benets:
● For dentures, denture impressions must be taken before coverage ends.
● For bridgework, crowns and gold restoration, the tooth must be prepared before
coverage ends, and the bridgework, crown or gold restoration must be installed within
the extended benet period.
● For endodontics, including root canal, the tooth must be opened before coverage ends,
and all covered services must be provided and charges must be incurred within the
extended benet period.
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Dental Plan HandbookPlan Year 2023
State Government Reduction-in-Force and Severance
Benets Act
You can reinstate dental insurance coverage at any time within two years following the date of
the reduction in force from the state if you are a former state employee who:
● Had a vested or retirement benet based on the provisions of any of the state public
retirement systems.
● Was separated from state service as a result of a reduction in force any time after
July 1, 1997.
● Was offered severance benets pursuant to the State Government Reduction-in-Force
and Severance Benets Act.
For further information, contact EGID Member Services. Refer to HealthChoice Plan Contact
Information.
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Dental Plan Handbook Plan Year 2023
State of Oklahoma
Ofce of Management and Enterprise Services
PRIVACY NOTICE
Revised January 2023
This notice describes how medical information about you may be used and disclosed
and how you can get access to this information. Please review this notice carefully.
For questions or complaints regarding privacy concerns with OMES, please contact:
OMES HIPAA Privacy Ofcer
2401 N. Lincoln Blvd., Ste. 300, Oklahoma City, OK 73105
405-717-8780 or toll-free 800-543-6044
TTY 711
oklahoma.gov/omes
Why is the notice of privacy practices important?
This notice provides important information about the practices of OMES pertaining to the way
it gathers, uses, discloses and manages your Protected Health Information and also describes
how you can access this information. PHI is health information that can be linked to a particular
person by certain identiers including, but not limited to, names, Social Security numbers,
addresses and birth dates.
Oklahoma privacy laws and the federal Health Insurance Portability and Accountability Act
of 1996 protect the privacy of an individual’s health information. For HIPAA purposes, OMES
has designated itself as a hybrid entity. This means that HIPAA only applies to areas of OMES
operations involving health care and not to all lines of service offered by OMES. This notice
applies to the privacy practices of the following OMES divisions and positions that may share
or access your PHI as needed for treatment, payment and health care operations:
● Employees Group Insurance Division (EGID).
● General Counsel Legal.
● Information Services as it applies to maintenance and storage of PHI.
● OMES Deputy Director.
● The Director of Policy and Legislative Affairs and the Legislative Liaison.
OMES is committed to protecting the privacy and security of your PHI as used within the
components listed above.
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Dental Plan HandbookPlan Year 2023
Your information. Your rights. Our responsibilities.
>
Your rights
When it comes to your health information, you have certain rights. This section explains
your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your health and claims records.
● You can ask to see or get an electronic copy of your medical record and other health
information we have about you. Ask us how to do this using the contact information at
the beginning of this notice.
● We will provide a copy or a summary of your health information, usually within 30 days
of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records.
● You can ask us to correct your health and claims records if you think they are incorrect
or incomplete. Ask us how to do this using the contact information at the beginning of
this notice.
● We may decline your request but will explain the reasons in writing within 60 days.
Request condential communications.
● You can ask us to contact you in a specic manner; e.g., home or ofce phone, or to
send mail to an alternate address.
● We will consider all reasonable requests.
○ If declining would put you in danger, tell us and we will automatically approve your
request.
Ask us to limit what we use or share.
● You can ask us not to use or share certain health information for treatment, payment or
our operations.
○ We are not required to approve your request and may decline if it would affect your
care.
Get a list of those with whom we’ve shared information.
● You can ask for an accounting of the times we’ve shared your health information for six
years prior to the date you ask, who we shared it with and why.
● We will include all the disclosures except for those about treatment, payment and health
care operations, and certain other disclosures (such as any you asked us to make).
● We will provide one free accounting per year but will charge a reasonable fee if you
request an additional accounting within 12 months.
Get a copy of this privacy notice.
● You can ask for a paper copy of this notice at any time, even if you have agreed to
receive the notice electronically. We will promptly provide you with a paper copy.
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Dental Plan Handbook Plan Year 2023
Choose someone to act for you.
● If you have named a medical power of attorney, or if someone is your legal guardian,
that person can exercise your rights and make decisions about your health information.
● We will verify the person has this authority and can act for you before any action is
taken.
File a complaint if you feel your rights are violated.
● You can le a complaint if you feel we have violated your rights by contacting us using
the information at the beginning of this notice.
● You may also le a complaint with the U.S. Department of Health and Human Services
Ofce for Civil Rights by sending a letter to 200 Independence Ave., S.W., Washington,
D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/
complaints/.
● We will not retaliate against you for ling a complaint.
>
Your choices
For certain health information, you can tell us your choices about what we share. If you
have a clear preference for how we share your information in the situations described below,
talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
● Share information with your family, close friends, or others involved in payment for your
care.
● Share information in a disaster relief situation.
● Contact you for fundraising efforts.
If you are not able to tell us your preference (e.g., if you are unconscious), we may share your
information if we believe it is in your best interest. We may also share your information when
needed to lessen a serious and imminent health or safety threat.
In these cases, we never share your information unless you give us written permission:
● Marketing purposes.
● Sale of your information.
● Most sharing of psychotherapy notes.
>
Our uses and disclosures
How do we typically use or share your health information?
Your PHI is used and disclosed by OMES employees and other entities under contract with
OMES according to HIPAA Privacy Rules and the “minimum necessary” standard, which
releases only the minimum necessary health information to achieve the intended purpose or to
carry out a desired function within OMES.
We typically use or share your health information in the following ways:
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Dental Plan HandbookPlan Year 2023
Help manage the health care treatment you receive.
● We can use your health information and share it with professionals who are treating
you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can
arrange additional services.
Run our organization.
● We can use and disclose your information to run our organization and contact you when
necessary.
● We are not allowed to use genetic information to decide whether we will give you
coverage and the price of that coverage. This does not apply to long term care plans.
Examples: We use health information about you to develop better services for you, provide
customer service, resolve member grievances, member advocacy, conduct activities to
improve member health and reduce costs, assist in the coordination and continuity of health
care, and to set premium rates.
Pay for your health services.
● We can use and disclose your health information as we pay for your eligible health
services.
Example: We share information about you with your dental plan to coordinate payment for your
dental work.
Administer your plan.
● We may disclose summarized health information to your health plan sponsor for plan
administration.
Example: Your employer contracts with us to provide a health plan, and we provide the
employer with certain statistics to explain the premiums we charge.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that
contribute to the public good, such as public health and research. We must comply with the law
to share your information for these purposes. For more information, refer to
hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues.
We can share your health information for certain situations such as:
● Preventing disease.
● Helping with product recalls.
● Reporting adverse reactions to medications.
● Reporting suspected abuse, neglect or domestic violence.
● Preventing or reducing a serious threat to anyone’s health or safety.
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Dental Plan Handbook Plan Year 2023
Do research.
We can use or share your information for health research, as permitted by law.
Comply with the law.
We will share information about you if state or federal laws require it, including with the
Department of Health and Human Services if it wants to ensure we are complying with federal
privacy laws.
Respond to organ and tissue donation requests.
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director.
We can share health information with a coroner, medical examiner or funeral director when an
individual dies.
Address workers’ compensation, law enforcement and other government requests.
We can use or share health information about you:
● For workers’ compensation claims.
● For law enforcement purposes or with a law enforcement ofcial.
● With health oversight agencies for activities authorized by law.
● For special government functions such as military, national security, and presidential
protective services.
Respond to lawsuits and legal actions.
We can share health information about you in response to a court or administrative order or in
response to a subpoena.
>
Our responsibilities
When it comes to your health information, we have specic obligations such as:
● We are required by law to maintain the privacy and security of your Protected Health
Information.
● We will let you know promptly if a breach occurs that may have compromised the
privacy or security of your PHI.
● We must follow the duties and privacy practices described in this notice and give you a
copy of it.
● We will not use or share your PHI other than as described here unless you notify us
in writing that we can. You may change your mind at any time but must let us know in
writing if you do.
For more information, refer to hhs.gov/ocr/privacy/hipaa/understanding/consumers/
noticepp.html.
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Dental Plan HandbookPlan Year 2023
Changes to the terms of this notice.
We can change the terms of this notice, and the changes will apply to all information we have
about you. The new notice will be available upon request, on our website, and we will deliver a
copy to you. You may also subscribe online to receive notice of changes to this page via email
or text message.
FRAUD, WASTE AND ABUSE
The Ofce of Management and Enterprise Services Employees Group Insurance Division is
committed to conducting its business activities with integrity and in full compliance with the
federal, state and local laws governing its business. This commitment applies to relationships
with members, providers, auditors and all public and government bodies. Most importantly, it
applies to employees, subcontractors and representatives of EGID. This commitment includes
the policy that all such individuals have an obligation to report problems or concerns involving
ethical or compliance violations related to its business.
If you suspect that EGID has been defrauded or is being defrauded or that resources have
been wasted or abused, report the matter to the EGID HealthChoice Program Integrity Unit
immediately. To report suspicious acts or claims:
● Send a report in writing to the EGID HealthChoice Program Integrity Unit at 2401 N.
Lincoln Blvd., Ste. 300, Oklahoma City, OK 73105.
● Email a message to [email protected].
● Call the EGID Fraud, Waste and Abuse toll-free hotline at 866-381-3815.
● Individuals are encouraged to provide adequate information to assist with further
investigation of fraud. All investigations will be handled condentially. Every attempt
will be made to ensure the condentiality of any report, but please remember that
condentiality may not be guaranteed if law enforcement becomes involved. There will
be no retaliation against anyone who reports conduct that a reasonable person acting
in good faith would have believed to be fraudulent or abusive. Any employee who
violates the non-retaliation policy will be subject to disciplinary action up to and including
termination.
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Dental Plan Handbook Plan Year 2023
PLAN DEFINITIONS
Allowable amount: HealthChoice pays benets based on set amounts known as allowable
amounts. This is the maximum amount HealthChoice will consider for payment for a covered
service or supply, regardless of the amounts billed by a provider. A network provider will
have agreed to accept the allowable amount as payment in full for the services rendered. A
network provider cannot bill you for amounts above the allowable amounts. If you use a non-
network provider that charges more than the plan’s allowed amount, you may have to pay the
difference. This is referred to as balance billing.
Example: A provider may charge $150 for a service. HealthChoice’s allowed amount is $90. A
network provider will accept the $90 in full as payment for the service. HealthChoice will pay up
to the $90, depending on any copayment or deductible you may owe. A network provider will
write off the remaining $60 and you cannot be billed for that amount. If you use a non-network
provider, then you may be responsible for everything that HealthChoice does not pay, up to the
full charge of $150.
Coinsurance: Coinsurance is a percentage of a medical charge that you pay, with the rest
paid by your health insurance plan, after your deductible has been met.
Cosmetic procedure: A procedure that primarily serves to improve appearance.
Deductible: The initial amount of out-of-pocket expenses you pay on allowable amounts
before a benet is paid by the plan.
EGID: The Ofce of Management and Enterprise Services Employees Group Insurance
Division.
Eligible dependent:
● Your legal spouse (including common-law spouse).
● Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child or child
legally placed with you for adoption up to age 26, whether married or unmarried. Note:
Plan coverage which terminates upon the dependent’s 26th birthday will terminate at the
end of the month in which the birthday occurs.
● Your dependent, regardless of age, who is incapable of self-support due to a disability
that was diagnosed prior to age 26. A Disabled Dependent Assessment form must
be submitted at least 30 days prior to the dependent’s 26th birthday. The Disabled
Dependent Assessment form must be approved by EGID before coverage begins.
● Other unmarried children up to age 26 who live with you and for whom you are primarily
responsible. This requires completion of an acceptable Application for Coverage for
Other Dependent Children. A tax return showing dependency can be provided in lieu of
the application.
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Dental Plan HandbookPlan Year 2023
Eligible employee: An employee of a participating employer who receives compensation
for services rendered and is listed on that employer’s payroll. This includes persons elected
by popular vote (e.g., board members for education, elected ofcials of state and local
government, rural water district board employees and county election board secretaries), state,
education and local government employees and any employee otherwise eligible who is on
approved leave without pay not to exceed 24 months.
● Education employees must be eligible to participate in the Oklahoma Teachers’
Retirement System and work a minimum of four hours per day or 20 hours per week.
● Local government employees, including rural water districts, must be employed in a
position requiring a minimum of 1,000 hours worked per year.
Eligible former employee: An employee who participates in any of the plans authorized
by or through the Oklahoma Employees Insurance and Benets Act who retired or vested
their rights with a state-funded retirement system or has the required years of service with
a participating employer. Surviving dependents and COBRA participants are considered as
former employees.
Network provider: A provider who has entered a contract with EGID to accept the plan’s
allowable amounts for services and supplies provided to plan participants.
Non-covered service: Any service, procedure or supply excluded from coverage and not paid
for by the plan.
Option Period: The annual time period established by EGID when changes can be made to
coverage.
Orthodontic limitation: A 12-month waiting period for orthodontic benets. No orthodontic
benets are available to members and/or dependents during the rst 12 consecutive months of
coverage. The 12-month waiting period does not exist if the treatment is for TMD.
Participating employer: Any municipality, county, or education employer or other state
agency whose employees or members are eligible to participate in any plan authorized by or
through the Oklahoma Employees Insurance and Benets Act.
Plan: The HealthChoice Dental Plan offered through EGID and described in this handbook.
Qualifying event: An event that changes a member’s family or dental insurance situation and
qualies the member and/or dependent for a special enrollment period. The most common
qualifying life events are the loss of health care coverage, a change in household (such as
marriage or birth of a child) or a change of residence. A complete summary of qualifying events
is set out in Title 26, Treasury Regulations, Section 125.
34
Dental Plan Handbook Plan Year 2023
This publication was printed by the Ofce of Management and Enterprise Services as
authorized by Title 62, Section 34. 150 copies have been printed at a cost of $1,185.00. A
copy has been submitted to Documents.OK.gov in accordance with the Oklahoma State
Government Open Documents Initiative (62 O.S. 2012, § 34.11.3). This work is licensed under
a Creative Attribution-NonCommercial-NoDerivs 3.0 Unported License.
35
Dental Plan HandbookPlan Year 2023
HealthChoice complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
and written information in other formats (large print, audio, accessible electronic formats, other formats). HealthChoice provides free language services
800-323-4314 (TTY: 711).
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
.
711).
(Spanish)
(Vietnamese)
(Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-323-4314 (TTY: 711).
(Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800-323-4314 (TTY: 711) 번으로 전화해 주십시오.
(German)
4314 (TTY: 711).
.(711: ) 800800--323- . : (Arabic)
(Burmese) သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 800-323-
4314 (TTY: 711) သုိ႔ ေခၚဆိုပါ။
(Hmong)
(Tagalog)
800-323-4314 (TTY: 711).
(French)
(Laotian) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ,
ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 800-323-4314 (TTY: 711).
(Thai)
เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 800-323-4314 (TTY: 711).
.(TTY: 711) 800-323-4314
(Urdu)
(Cherokee) Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 800-323-4314 (TTY: 711)
(TTY: 711) 800-323-4314(Farsi)
36
Dental Plan Handbook Plan Year 2023
NOTES
HealthChoice is administered by EGID, a division of the
Oklahoma Ofce of Management and Enterprise Services.
