Dental insurance is provided by
Securian Dental Plans/Decare Dental Health International LLC,
P.O. Box 231, Minneapolis, MN 55430-0231
Dental Forms (click to download)
Dental Membership Enrollment Form – see instructions below
Dental Membership Maintenance Form
Section 125 Cafeteria Plan Benefit Election Form (dental/health premiums paid on pre-tax basis-see info at end)
Note: When the above forms are completed, they should be sent to Suzanne Levesque in Payroll, NOT to Securian Dental.
Dental Membership Enrollment Form Instructions
Important Information: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for purposes of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties.
- all dates should be written in MM/DD/YYYY format.
- When reporting effective dates, use contractual start and stop guidelines as defined in your contract (i.e., first of the month, end of month, or actual dates).
- Before submitting, review it to ensure you have provided all necessary information.
- If information is missing or illegible, this form will be returned to you and may delay your enrollment.
- Enrollment requests are generally completed within five business days of receipt of Securian Dental Plans.
PART A: EMPLOYEE INFORMATION (complete all sections)
PART B: CHANGE REQUEST (check one or more categories that apply and provide information as requested by category)
- Name Change – Provide name as previously reported and new name.
- Terminate Employee and All Dependents – Only use this section if the employee and all dependent coverage is being terminated.
- Change Employee Group/Subgroup – Move employee from one group/subgroup number to another for benefit, reporting or COBRA purposes.
- Change Plan Option – Applies only to employer groups that offer more than one Plan Option and have Open Enrollment. An employee may select a new Plan Option during the Group’s Open Enrollment.
- Coverage Type Change – Complete this section to change Coverage Type and to add or drop dependent coverage. Coverage Type change requires a qualifying event (i.e., marriage, divorce, etc.). List Qualifying Event Code on line next to correct Coverage Type. Provide detailed information for each dependent being added or dropped in Part C.
PART C: DEPENDENT INFORMATION
- List dependents to be added or dropped when making a change to Coverage Type in Part B.
- Complete all sections for each dependent.
- If more than four dependents are being reported, attach a list of additional dependent information in same format.
PART D: EMPLOYEE SIGNATURE: Please read, sign and date the form as verification of your change request, then return completed form to Suzanne Levesque in Payroll.
PART E: COBRA
Indicate whether the COBRA benefits are Group Billed or Direct Billed. Direct Billed means the employee is billed by Securian Dental and makes payments directly to Securian Dental. Group Billed means COBRA is billed by Securian Dental; the Group receives payment from the employee; the Group then pays Securian Dental for COBRA contination.
- Select a coverage type election, the appropriate Qualifying Event Reason Code and provide the date of the qualifying event.
- If employee is not being enrolled for COBRA, provide the Social Security Number of the individual who is being enrolled.
- If your group has separate COBRA subgroup, it must be provided in Part B.
- Do not send Direct Billed COBRA requests to the Enrollment Department. To avoid delays or termination of benefits, send all Direct Billed Information to: Securian Dental Plans, Attention: Coverage Continuation, P.O. Box 231, Minneapolis, MN 55440-0231
PART F: GROUP INFORMATION (completed by employer)
DENTAL BENEFIT PLAN OVERVIEW
Deductible (primary care and prosthodontic care services combined)
Level of Benefits: $25 individual/$75 family
Calendar Year Maximum (preventive, primary care and
prosthodontic care services combined) Level of Benefits: $1,000
A separate deductible is required for each member receiving services.
There is protection from balance billing if you visit a Network Participating Dentist.
Domestic partners are eligible for coverage.
Preventive Services (Type I) – 100% of maximum allowance
oral exams (twice a year)
cleanings (twice a year)
fluoride treatments (under 18, twice in a 12-month interval)
sealants (coverage thru age 15)
space maintainers (for premature loss of baby teeth)
Primary Care Services (Type II) – 80% of maximum allowance
endodontics (root canals)
periodontics (diseased gum tissue or bone)
repair of dentures, partials, or bridge
Prosthodontic Care Services (Type III) – 50% of maximum allowance
dentures and bridges
crowns and prosthetics
Orthodontic Care (Type IV) – 100% lifetime maximum
services available for individuals under age 19
initial orthodontic exam, diagnostic casts, and x-rays
services and supplies for orthodontic appliances
SUMMARY SCHEDULE OF BENEFITS
Group Name: Brunswick School Department
Group Number: 8093-0003, 8093-0103, 3093-0099, 8093-0199, 9183-0009
Effective Date: July 1, 2004
BENEFIT LEVELS, COINSURANCE & WAITING PERIODS
Coverage A-Diagnostic & Preventive (coinsurance is 100%)
Coverage B1a-Basic Services:: (coinsurance is 80%)
Coverage B1b-Endodontics: (coinsurance is 80%)
Coverage B1c-Periodontics: (coinsurance is 80%)
Coverage B1d-Oral Surgery (coinsurance is 80%)
Coverage B2-Major Restorative (coinsurance is 50%)
Coverage C1-Prosthetic Repairs & Adjustments (coinsurance is 80%)
Coverage C2-Prosthetics (coinsurance is 50%)
WILL ORTHODONTICS BE COVERED?
Yes, 50% coinsurance, with lifetime maximum at $1,000
DEDUCTIBLE (applies to coverage B1a-C2):
coverage year maximum is $1,000
COORDINATION OF BENEFITS: standard
062300: Assignment of Benefits
062295: Coverage for Denturist Services
062270: Dental Network I
062294: Late Enrollees Eligible at Open Enrollment
062297: Dental Prophylaxis, twice per year
SECTION 125 CAFETERIA PLAN BENEFIT ELECTION FORM This cafeteria plan allows participants to make payments for certain employer-sponsored benefits plans with pre-tax dollars. By agreeing to reduce your salary by the amount of your contribution, you will generate Benefit Account Dollars which are not subject to FICA or federal and state income taxes. Any election you make to fund your benefits under the provisions of this plan will remain in effect until the end of the plan year unless one of the following family status changes occurs, in which event an election may be revoked or changed.
- legal marital status including marriage, divorce, legal separation or annulment
- death of a spouse or death of a dependent child
- change in employment status (employee, spouse or dependent) from commencement of work, full-time to part-time or vice versa, unpaid leave of absence, strike or lockout or termination of employment affecting eligibility under an employee benefit plan
- a change in residence of the employee, spouse or dependent that affects eligibility coverage
- dependent satisfies or ceases to satisfy dependent eligibility requirements