CDA Benefits Plan - FAQ
1. Does the dentist have to be on this plan?
No. He/she has to have current membership in the Colorado Dental Association.
2. How many people in the office have to participate?
There is a 75% participation requirement for an office choosing the non-medically underwritten plans. This is based on 75% of the eligible employees in the office who do not have coverage on other plans. For the medically underwritten Outlook PPO Plan, there is a 50% participation requirement for the office.
3. Does everyone in the office have to be on the same Plan?
This may be an office designation, but the CDA Benefit Plan allows everyone to be on separate Plans/deductibles, with the exception of Outlook PPO.
4. What about pre-existing conditions?
A pre-existing condition is a condition for which medical advice, diagnosis, care or treatment, including services and supplies, consultations, diagnostic tests or prescriptions medicines, was recommended or received within the six months prior to the enrollment date. The period for which claims can be paid for such a condition can be reduced by receipt of a letter of Creditable Coverage from the prior carrier(s). A Timely Enrollee has a 6-month pre-existing waiting period from the date of hire or qualified status change. A Late Enrollee has an 18-month pre-existing waiting period from the effective date of coverage.
5. What about a drug card?
The CDA Benefit Plan has a drug card. CNIC issues a combination medical and prescription ID card. It uses the WellDyne Rx Network. This includes all of the major pharmacies (Albertson's, City Market, Kmart, King Soopers, Safeway, Walgreens, Wal-Mart, etc.). The $1,250 and $3000 Plans/deductibles have prescription co-pays. The $1,500, $2,500 and $10,000 Plans/deductible have prescriptions subject to the single medical/prescription deductible. The $5,000 deductible Plan has a $1,000 deductible that is separate from the medical deductible. This allows a person to choose this high medical deductible and still have drug card benefits. You need to have your pharmacist use your prescription card from the beginning for prescriptions to apply to the Rx deductible. Please see the Plans descriptions for further details.
6. What about well care?
All of the plans cover wellness benefits at 100% for in-network providers. Please refer to the Preventive Care section of the plan descriptions for further details.
7. How much does it cost?
The rates are based upon the Plan/Deductible and the age of bracket of the insured. The rates change at the beginning of the month in which a birthday occurs when the birthday moves an insured into a higher age-band. At age 65, the rates decrease because this Plan becomes secondary to Medicare.
8. Do I need a PCP (Primary Care Physician)/Referral?
No. These are PPO Plans and do not require referrals or a PCP.
9. How many hours a week do I have to work? Is this per week or an average?
20 hours a week is the minimum. This can be averaged in a month for people who have variable schedules.
10. What if I work for two dentists, am I eligible?
As long as the enrollee works 20 hours a week for one or more CDA member dentists, he/she is eligible. If one dentist is not a CDA member, as long as she works for the CDA member dentist the minimum number of hours, it is ok. If both dentists are CDA members, the total hours a week worked can be combined and must meet the minimum of 20 hours.
11. Which Plan is the best?
This depends on who is asking: the payer or the participant. If the payer is deciding, their criteria may different than that of the participant. It would depend on individual situations and how a participant uses health care coverage. If basic coverage is all that is needed, such as annual wellness benefits and an occasional office visit, a higher deductible with lower costs per month may be the best choice. Others may not be comfortable with the risk of a high deductible and prefer a lower deductible.
12. How old can my children be and still be covered?
All dependent children must be unmarried. Dependent Children are covered automatically up to their 19th birthday. If they are age 19 through 24 and they are either financially dependent on or living with the employee, they remain eligible. From age 24, to 29, they need to be financially dependent and either a full-time student or missionary. It is the insured's responsibility to provide proof of full time student status for their dependents when they first turn 19 and every fall from that time on.
13. How do I pay for it?
The payment can be drafted monthly from an individual or business account. The draft is taken in arrears and will be take on the 20th of the month or the first business day thereafter if the 20th falls on a weekend or holiday. This means that the draft for January (for instance) would fall on the 20th of January. Most people pay this way. Usually, the office will take a payroll deduction for the portion of the monthly payment that the employee must pay; such as for dependents or the employee portion if the office does not cover the entire amount. We can draft separate accounts for people in the same office, such as one account for the dentist and another account for employees. However, we cannot draft two accounts for one participant. If your office has had coverage on this plan at any time prior to January 1, 2004, we can also draft an employee's account for his or her own coverage. The draft is reflected on the bank statement. Offices that pay for employee(s) will receive a letter every time there is a change in the draft for any reason - age increase, change in dependent status, change in Plans, etc. What is necessary to establish a draft is to complete the Authorization Agreement for Electronic Payment form and a copy of a check from the correct account. Some people wish to pay by check on a monthly, quarterly, semi-annual or annual basis. We will invoice them. There is a $5.00 invoice fee for all but the annual invoice, which is imposed by the Board and goes to the Plan. This $5.00 is per invoice and not per person, so a monthly office invoice for three people would still be only $5.00.
14. How do I sign up?
The basic Enrollment Form will need to be filled out for all plans. If you are applying for the Outlook PPO Plan, you will also need to fill out and submit the Outlook PPO Employee Application for medical underwriting. There is an authorization for automatic drafts. If a participant is to be invoiced, they can write on the front "Please Bill me Monthly." If you are being added to an existing account, please note that on the front. The completed form may be faxed to (303) 770-5673 or mailed to CDA Benefit Plan, C/O CNIC Health Solutions, PO Box 3559, Englewood, CO 80155-3559.
15. Who do I contact to make changes on my coverage (such as adding dependents, providing proof of prior coverage, full time student status, terminating my coverage, changing my payment information, etc.)?
All new enrollments, coverage changes, forms verifying dependent eligibility and/or student status or proof of prior coverage, payments, etc. should be directed to Sue Donovan at CNIC Health Solutions, the Contract Administrator for the CDA Benefit Plan. The address is: CDA Benefit Plan, C/O CNIC Health Solutions, PO Box 3559, Englewood, CO 80155-3559. CNIC Health Solutions acts like your "Human Resources Department." We handle all changes, documentation, verification, receipt of payment, termination requests, address changes, etc. for the CDA Benefit Plan. You should always receive a letter of confirmation from the CDA Benefit Plan whenever a change is made or documentation is sent in. Please feel free to contact Sue Donovan at (303) 770-5710 or (800) 232-2588, extension 1269.
16. When will the coverage start?
Coverage begins on the first of the month after the appropriate waiting period. The waiting period is either the first of the month following two months from date of hire (DOH), or the first of the month following the employer's designated waiting period. The waiting period cannot be less than 30 days from date of hire and always begins on the first of the month for new employees. We keep employers' Waiting Period Designation forms on file and apply the waiting period to every enrollment received. Employees requesting coverage when coming on through a qualified status change, such as an involuntary loss of coverage, marriage, etc., would be eligible to begin coverage as of the day following the qualified status change or the first of the month thereafter. For those coming on without a qualified status change, they would be considered a late entrant and can only begin coverage during the open enrollment period with an effective date of January 1st.
17. Can I add my common law spouse?
Yes. The State of Colorado recognizes common law marriages. If the enrollment form has different last names for spouse and participant and does not show a date of marriage, marital status must be verified. Either the enrollee must complete the form with the date of marriage, or an affidavit must be signed declaring common law marriage. This means the participant must go through a legal divorce to end the marriage.
18. Can I add my fiancé?
No. Only legal spouses and dependents meeting the definition can be added.
19. How long does it take to get coverage?
The processing of an enrollment takes a few days. Coverage will begin as noted above (#16), on the first of the month following the appropriate waiting period.
20. How do I add my children, spouse to my coverage?
A dependent can only be added through a qualified status change or at open enrollment. A Status Change Form can be completed and faxed for mailed to the CDA Benefit Plan (see #15). When adding a spouse or dependent through a qualified status change, such a marriage, loss of other coverage, new birth, etc., coverage begins on the date of the qualifying event. If you are adding a dependent(s) that was on the plan previously, he/she can only be added during mid-year if there is a loss of that dependent's coverage or if they are newly eligible as a dependent. Dependents that do not have a qualified status change must wait until Open Enrollment, which would be effective January 1st.
21. How do I change my name?
Either by submitting a Status Change Form or a letter with the previous name and the new one, clearly written, and the date and signature of the insured to the CDA Benefit Plan (see #15).
22. How do I drop someone from my coverage?
A written request with the date and signature of the insured must be received. (See #15) It must state the dependent's name, the reason for dropping the dependent and the desired effective date. The dependent will be dropped at the end of the month in which the request is received or the end of the month requested, whichever is later unless the dependent no longer meets the definition of a dependent. If the dependent no longer meets the definition of a dependent, the notification must be received within 30 days of the loss of dependent status for COBRA information to be sent. The term date will go back to the last day of the month in which a dependent was eligible. Adjustments resulting in payment charges will only be made for one month back, where applicable.
23. My child is no longer a full time student. How can I continue coverage?
Notify the Plan is writing of the last day of dependent eligibility (such as no longer being financially dependent upon the employee, getting married or losing full-time student status if age 25 or older). (See #15) Dependent coverage will end at midnight of the last day of the month in which the dependent loses dependent status. COBRA information will be sent to the dependent if the Plan is notified within 30 days of the qualified status change. Loss of dependent status results in a possible 36-month period of COBRA coverage.
24. When can I lower my deductible or change Plans?
Every October, notification is sent to all participants at home, and all offices that pay for coverage, of the Annual Change Period, which are during the months of November and December. During that period, participants can change their plans/deductibles for an effective date of January 1st. There is no medical review and this does not change your pre-existing condition waiting period. Anyone can change and begin a new Plan in January.
25. Is there any carry-over on the deductible?
Yes on the $1,250, $3,000, $5,000 and $10,000 deductibles. Any deductible that is met in the last three months of the year, without meeting or exceeding your deductible, will be carried over to the following year. You will never start off the year with a zero deductible. If you change your deductible for January to a lower deductible which would result in your entire deductible having been met, no deductible would be carried over (ie. If you were on a $3,000 deductible, met $1,500 of that deductible in November and then changed to a $1,250 deductible for January, not deductible would carry over.) The $1,500 and $2,500 plans are not eligible for carry-over deductibles due to restrictions for HDHP plans.
26. I'm going out of the country. Am I covered?
Yes. There is coverage for emergency benefits. In this case, the participant must pay the bill for services at the time of service and get a copy in English, with as much detail as possible. Submit the bill to the Plan; it will be processed according to the provisions of the Plan and reimbursement will be based on the exchange rate on the date of receipt.
27. My employer will not pay for this; can I still have coverage?
If anyone has had coverage through this office/dentist prior to January 1, 2004, you may enroll in this Plan and pay for your own coverage as long as the eligibility requirements have been met. If no one has ever been covered on this Plan through this office/dentist prior to January 1, 2004, payment must be made through the office and the dentist is expected to pay 50% of the employee's portion.
28. Where should the claims be sent?
Claims should be sent to CNIC Health Solutions, PO Box 3559, Englewood Co 80155-3559.
29. Is this coverage 24/7?
No. This coverage does not pay for any workers' compensation injury or illness, for any dentist or employee; regardless of what workers' compensation coverage is carried or not carried by the dentist.
30. Is my doctor on the list? How do I find out?
The network is Rocky Mountain Health Plans ASO Solutions. The best way to determine if your doctor participates in the network is to look them up on the Internet at www.rmhp.org. When looking for a provider, you will have to select the ASO Solutions product. Participants have greater benefits if they go to a network provider.
31. What pharmacies can I go to?
Any WellDyne Rx participating pharmacy. You may call 1-888-479-2000 or go on-line to www.welldynerx.com to find out if your pharmacy is a participant or not.
32. What if I don't have a pharmacy card?
The medical ID card has the pharmacy information on the bottom of it. If you need a new ID card, please contact CNIC.
33. How can I change the bank account that is drafted for my coverage?
Send, or fax, a completed Authorization Agreement for Electronic Payment form and a copy of a check from the correct account and the effective date for the change to Sue Donovan at CNIC Health Solutions, the Plan Administrator for the CDA Benefit Plan. The fax number is (303) 770-5673. The address is: CDA Benefit Plan, C/O CNIC Health Solutions, PO Box 3559, Englewood, CO 80155-3559. Information for the draft must be processed through the Plan to the bank prior to the draft. Therefore, all bank change requests must be received by the Plan by the 10th of the month in order to be assured that the change will be effective for that month's draft.
34. What has to be preauthorized?
Please contact CNIC Health Solutions at 1-800-426-7453 for information on what needs to be preauthorized and the procedure for preauthorization.
35. How do I terminate my coverage?
A written request for termination is required. This notification must be sent or faxed to the CDA Benefit Plan (see #15). It can come from the insured or the payor (the office). If a COBRA Qualifying Event has occurred, COBRA coverage information will be sent, whether or not the employee is requesting it. Termination is not retroactive, unless the coverage has not been paid for. Coverage ends on the last day of the month in which the written notice is received and is never pro-rated.
36. How do I get COBRA?
If eligible, upon receipt of notification of termination of employment or other COBRA Qualifying Event, COBRA election information is sent to the participant and/or all qualified dependents at their home address that is on file with CNIC. The participant and dependents have independent rights to elect COBRA, and must respond by the election date stated in the letter.
37. Who do I talk to about an unpaid claim?
You should contact customer service at CNIC at 1-800-426-7453 regarding unpaid claims. It is helpful to find out the date of service and where the claim was sent. Claims can be processed up to one year from date of service.
38. What is my policy number?
The group number 22202992. You are assigned a Unique ID number.
39. What is the insurance company?
There is none. The CDA Benefit Plan, Inc. is a non-profit organization set up to provide medical coverage for CDA member dentists and their employees. This is a Trust, established in 1981. The Board of Directors is made up of volunteer dentists who are on the Plan. The coverage is determined by the Board of Directors. CNIC Health Solutions is the Contract Administrator hired by the Board to do the enrollment for the Plan. Rocky Mountain Health Plans ASO is the PPO network.
40. Can I retire and keep this coverage?
For dentists on the Plan for two continuous years or who are ages 65 or older at the time of retirement, they can retire or reduce their hours to less than 20/week at any time and keep this coverage as long as they maintain their CDA membership. The payment will decrease when age 65 is reached; this is not related to working status, but due to Medicare becoming primary. Employees who are not dentists cannot retire on this Plan.
41. Can my wife/dependents stay on the Plan if I should die?
For CDA Member Dentists, your spouse can remain on the Plan as long as desired, as long as he/she does not remarry. Dependents can remain on the Plan as long as they maintain what would be considered dependent status. For employees that are not CDA Member Dentists, your dependents would be eligible for up to 36 months of COBRA coverage.
42. What about Medicare?
Medicare becomes the primary coverage at age 65 for all participants who work in an office with less than 20 employees, whether or not the participant has signed up for Parts A and B. This Plan is secondary to Medicare at age 65 for all insured participants, whether or not they continue to work. All participants are encouraged to sign up for both Parts A and B of Medicare. A letter is sent explaining this in the month prior to their 65th birthday.
43. Do all Plans/Deductibles qualify for Health Savings Accounts?
No. Currently, the only Plan qualified to enroll in a Health Savings Account is the $2,500 HDHP plan. While other Plans have higher deductibles, they do not qualify, in part, because they do not have single family deductible and they offer office co-pays, which are not allowed for Health Savings Accounts.