When does my coverage start?
Coverage starts on the effective date. The effective date issued will begin on the first of the month (at 12:00 a.m.) following HPA, Inc.’s receipt of the completed Enrollment Form and payment of the first month of premium.


Who is eligible for this coverage?
This plan is offered to individuals ages 18 years and older, their spouses, and their eligible dependents.


How are benefits covered?
Secure DentalOne pays benefits for each covered person in the following manner:

First, you meet the $100.00 Lifetime Deductible per covered person.

Then Secure DentalOne pays a percentage of covered expenses based on the Reasonable and Customary (R&C) fees for those Covered Expenses.


BasicOne* ClassicOne PremierOne
Waiting Periods
Preventative 0 0 0
Diagnostic N/A 0 0
Basic N/A 6 months 0
Major N/A 12 months 0
Coinsurance Graded Benefit
Preventative 80% 80% 100%
Diagnostic N/A 80% 100%
Basic N/A 50% 25/50/75%**
Major N/A 50% 10/20/40%**
Office Co-pay N/A N/A $10
Deductible N/A $100 lifetime applies
to all services $100 lifetime applies
to all services
Calendar Year
Maximum N/A $750 $1250
*BasicOne option subject to PPO MAC pricing
**Year 1/Year 2/Year 3


Preventive Care
Routine oral exams—limited to 2 per calendar year
Prophylaxis (the cleaning and scaling of teeth) — limited to 2 per calendar year
Topical application of fluoride—for dependent children under age 19; limited to 1 per calendar year (not applicable in all states)

Diagnostic Care*
Intra-Oral Occlusal Film
Bitewing X-rays (up to a set of 4)—limited to 1 per calendar year
Full mouth X-rays (Panoramic film or Full series)— no less than 36 months apart

Basic Care*
Simple extraction
Pin retention—per tooth, in addition to restorations
Fillings (restorations)
Amalgam restorations
Composite restorations—limited to anterior teeth and bicuspids
Sedative fillings
Antibiotic injections administered by a Dentist
Maintenance Prosthodontics
Denture repairs/Adjustments
Denture Rebase—no less than 24 months apart
Denture Reline—no less than 24 months apart

Major Care*
Endodontic treatment
Periodontic services
Inlays, onlays and crowns
Prosthetic services—dentures or bridges
Oral surgery

*Applies only to ClassicOne and PremierOne options



What is Secure DentalOne?
Secure DentalOne offers you access to quality, affordable dental coverage for your entire family. Coverage is provided for preventive, basic and major dental services.

Exclusive Features:

•Choice of $750 or $1,250 maximum per person
•No waiting period for Preventative Care
•Eligible for ages 18 years and older
•Benefits for preventive, diagnostic, basic, and major services
•Automatic Bank Draft, Visa, MasterCard, or Discover

Three plan options available:

•Choose from our BasicOne, ClassicOne and PremierOne plans

One deductible, for life:

•Save in the long-term through our unique $100 lifetime deductible



What is the OrthoCare Program?

The OrthoCare Orthodontic Discount Program* is an optional program for orthodontic care. When using a contracted OrthoCare Orthodontist, you will save 15% - 20% on the services performed. The OrthoCare program has been designed to offer orthodontic benefits to both individuals and families, providing benefits for the routine orthodontic treatment for children and adults. Children who are dependents are covered under the family plan up to their 23rd birthday. OrthoCare has no waiting periods before the benefits begin.
FIND A LISTING OF PARTICIPATING ORTHODONTISTS AND DETAILED COVERED and EXCLUDED BENEFITS
Visit our web site www.amdps.com

•No Deductibles
•No Waiting Periods
•No Claim Forms
•No Prior Authorization Required
•Affordable Rates
•Coverage for Children and Adults

*The optional OrthoCare Program is not an insurance benefit, nor is it affiliated with Standard Security Life Insurance Company of New York or a part of the Secure DentalOne insurance plan.



Who is the Association?

Communicating for America, Inc.** (CA) provides many benefits and discounts to its members. Your enrollment as a member of CA is completed upon receipt of the association annual dues included in your enrollment fee.

**CA is not affiliated with Standard Security Life Insurance Company of New York, nor is it a part of the insurance coverage. CA is a 501c5 non-profit association headquartered in Fergus Falls, Minn., providing members valued benefits and savings since 1972.

Communicating for America’s (CA), offering exclusive dental and lifestyle benefits to members of CA.

CA provides additional consumer benefits and services you can use to stay healthy and reduce your medical expenses. These benefits include:

Coaches and advocates

Discount prescription drug card
All members receive a FREE discount prescription drug card..

Discounted services

Voicemail transcription
Voice mail transcribed into text and received as e-mails or text messages.

Remote file sharing service that allows you to easily share large computer files, photos and videos with clients or colleagues.

Remote PC access
The ability to remotely access you office PC from home, or your home computer at work.

Remote meeting
Live video meeting service that allows you to converse with clients over the Internet.

Remote backup
Automatic backup of your personal PC over the Internet for safer file storage at remote location.



What are my payment options?
You can pay Monthly through auto bank withdrawal or credit card. Quarterly or Annually can be paid by credit card. Your subsequent monthly credit card/ach premium deductions will occur based upon the effective date of coverage. If your coverage effective date is the 1st - 14th, your premium will be deducted on the 1st of the month. If your coverage effective date is the 15th - 31st, your premium will be deducted on the 15th of the month.


Is there a free look period?
If you are not completely satisfied with this coverage, and you have not filed a claim, you may return the Certificate of Insurance within 10 days and receive a premium refund. Enrollment and Administrative fees are non-refundable.


What is the calendar year maximum?
The maximum amount payable for all Covered Dental Charges in any calendar year as shown in the Coverage Schedule. The Calendar Year Maximum will apply to each insured person.


What is the Maximum Allowable Charge (MAC)?
The BasicOne plan is a PPO plan using the Dentemax PPO network and fee schedule for in and out of network benefits. The MAC benefit is payable as a percentage of the network fee schedule regardless of whether the treatment is provided by a network provider. Out-of-network charges in excess of the net work fee schedule are the responsibility of the covered person.


What is a Covered Charge?
Expenses must be incurred while the coverage is in force and the person is covered by the Policy. To be a covered charge, the dental services must be performed by:

•A licensed Dentist acting within the scope of his license
•A licensed Physician performing dental services within the scope of his license
•A licensed dental hygienist acting under the supervision and direction of a Dentist.




When is a Covered Charge considered incurred?
A covered charge is considered incurred on the following dates:


•For full and partial dentures—on the date the first impression is taken.
•For fixed bridges, crowns, inlays and onlays—on the date the teeth are first prepared.
•For root canal therapy—on the date the pulp chamber is opened.
•For periodontal surgery—on the day surgery is performed.
•For all other services—on the date the service is performed.




Predetermination of Benefits?
Except in an Emergency, if You need treatment which will cost more than the Predetermination Amount shown on the Schedule of Benefits page, Your Dentist must submit a claim to Us before beginning treatment which describes the treatment necessary and its cost. We have the right to request any additional information We deem necessary to evaluate this claim. This includes, but is not limited to, dental records and X-rays. We will prepare and return to You and Your Dentist an estimate of the treatment and the amount for which benefits are payable. This estimate is not a guarantee of payment by Us. We will still consider a claim for which You have not obtained prior approval. These claims will be subject to reduced benefits based on Our determination of Reasonable and Customary Charges and Medically Necessary treatment.


Coordination of Benefits?
This coverage will be coordinated with any other group, blanket or franchise plan under which a covered person will receive benefits. This helps keep the cost of the plan reasonable.


What is a reasonable and customary fee?
The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the Geographic Area in which the charge is incurred. The most common charge means the lesser of:

•The actual amount charged by the provider
•The negotiated rate
•The usual charge which would have been made by a provider (Dentist, Hospital, etc) for the same or comparable professional services, drugs, procedures, devices, supplies or treatment within the same Geographic Area as determined by Us. “Geographic Area” means the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; or a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.




What is an alternate benefit?
An alternate benefit will apply: (1) If we determine that a less expensive alternative procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and (2) the alternative treatment will produce a professionally satisfactory result; then the maximum we will allow will be the Reasonable and Customary charge for the less expensive treatment.


What services are not covered?
Treatment, services or supplies which:

A. Are not Medically Necessary;
B. Are not prescribed by a Dentist;
C. Are determined to be Experimental/ Investigational in nature by Us;
D. Are received without charge or legal obligation to pay;
E. Would not routinely be paid in the absence of insurance;
F. Are received from any Family Member;
G. Are not Covered Procedures.

•Self inflicted injuries.
•War or an act of war, whether or not declared.
•A Covered Person's commission of a felony or an assault on another person.
•Riot, nuclear accident, or a major disaster.
•Employment; whether caused by, related to, or as a condition of employment, including self employment. This exclusion applies even if Workers' Compensation or any Occupational Disease or similar law does not cover the charges.
•Treatment which began, before the Covered Person's Effective Date of coverage or after the Covered Person's termination of coverage.
•Congenital or development malformations existing on the Covered Person's effective date as shown on the Schedule of Benefits.
•Implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments, unless the coverage is elected by the Insured Person and the required premium is paid.
•Periodontal splinting.
•Porcelain on crowns, or pontics posterior to the 2nd bicuspid.
•Replacement of partial or full dentures, fixed bridge work, crowns, gold restorations and jackets more often than once in any 5 year period.
•Relining of dentures more often than once in any 2 year period.
•Lost, stolen, or missing dentures or bridges or for duplicates.
•Fixed or removable bridgework involving replacement of a natural tooth or teeth which was lost prior to the Covered Person's Effective Date of coverage as shown on the Schedule of Benefits. Benefits may be payable for bridgework required for loss of teeth while covered under the Policy, if such bridgework is not an abutment for non-covered bridgework.
•Prescription Drugs and analgesia pre-medication.
•Telephone consultations, failure to keep a scheduled appointment, to complete claim forms or attending Dentist statements, and any other services or supplies which are not part of the direct treatment of the Covered Person.
•Dental education or training programs including oral hygiene or plaque control programs.
•Counseling on diet and nutrition.
•Military service, including service in a military reserve unit.
•Prosthodontics, unless this coverage is elected by the Insured Person and the required premium is paid.
•Charges payable under any medical insurance.
•Charges made by any government entity unless the Covered Person is required to pay; or by any public entity from which coverage could have been obtained by application or enrollment even if application or enrollment was not actually made.
•Use of materials, other than fluorides or sealants, to prevent tooth decay.
•Bite registrations.


•Bacteriologic cultures in connection with a covered dental service.
•Therapeutic injections administered by a Dentist.
•Cast restorations, inlays, onlays and crowns for teeth that are not broken down by extensive decay or accidental injury or for teeth that can be restored by other means (such as an amalgam or composite filling).
•Replacement of 3rd molars.
•Composites on teeth posterior to the 2nd bicuspid.
•Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps, or existing large restorations without overt pathology.
•Temporomandibular joint syndrome.
•Cosmetic procedures
•Orthodontia


Brief Statement of Policy Provisions Relating to Premiums, Renewability, and Termination The Policy is renewable at the option of the Association or the Insurer. The Insurer reserves the right (subject to state specific requirements) to change the premiums upon 31 days prior to written notice. Coverage may be terminated by the Policyholder or the Insurance Company upon 31 days written notice to the other party, and for other reasons stated in the group policy, such as: failure by the Policyholder to pay the required premium; if you are no longer eligible for this insurance; or you are no longer in an eligible class.



Definitions?
The terms listed below, when used in relation to the Coverage, will have the following meanings:

Calendar Year: The period of time beginning January 1st and ending on December 31st of the same year. The first Calendar Year of the Certificate will begin on the date Your coverage becomes effective and end on the first December 31st after a Covered Person’s Effective Date of coverage.

Calendar Year Maximum Amount: The maximum amount of benefits payable under the Certificate in a Calendar Year. The Calendar Year Maximum is shown on the Schedule of Benefits page. Prosthodontics and orthodontia, if covered, have a separate Calendar Year Maximum Amount.

Certificateholder: The Insured Person under the Policy.

Child:

•An Insured Person’s natural child;
•An Insured Person’s lawfully adopted child;
•A child placed for adoption with an Insured Person;
•An Insured Person’s stepchild;
•An Insured Person’s foster child;
•A child for whom the Insured Person has been appointed legal guardian by a court of competent jurisdiction and who resides with and who is dependent upon the Insured Person in a regular parent-child relationship; or
•A Child of the Insured Person for whom the Insured Person is obligated to provide medical child support pursuant to a Qualified Medical Support Order, provided that the requirement for qualifications of the order as outlined in the Policy are met.

Co-Insurance: The percentage paid by the plan after the Deductible is met up to the Calendar Year Maximum Amount. The Co-Insurance percentage is shown in the Schedule of Benefits.
Company: Standard Security Life Insurance Company of New York. Also hereinafter referred to as We, Us and Our.

Copay/Copayment: The fixed dollar amount specified in the Schedule of Benefits that is payable by a Covered Person to a provider at the time of service in connection with specific Covered Charges.

Covered Charge: The Reasonable and Customary Charge for a Medically Necessary Covered Procedure which is performed by a Dentist or a Dental Hygienist acting under the supervision and direction of a Dentist.

Covered Person: A person who has satisfied all of the following requirements:

•he or she is eligible for coverage under the Policy, either as an Insured or as a Dependent;
•he or she has been accepted for coverage under the Policy or has been automatically added;
•premium has been paid for him or her; and
•his or her coverage has become effective and has not terminated.

Covered Persons are shown on the Identification Card.
Covered Procedure: The procedures listed in the Schedule of Covered Procedures. The procedure must be: (1) for Medically Necessary dental treatment to a Covered Person while his or her coverage under the Policy is in force and (2) for treatment, which in Our opinion, has a reasonably favorable prognosis for the patient. The procedure must be performed by a:

•licensed Dentist who is acting within the scope of his or her license;
•licensed Physician performing dental services within the scope of his or her license; or
•licensed Dental Hygienist acting under the supervision and direction of a Dentist.

Deductible: The dollar amount for Covered Procedures that a Covered Person must pay in a Calendar Year before benefits are payable under this Certificate. The Deductible is shown on the Schedule of Benefits. Each Covered Person must satisfy the Deductible before benefits are payable. After three Covered Person's have each satisfied the Deductible, no additional Deductible will be required for other Family Members who are Covered Persons for the remainder of the Calendar Year.

Dentist: A person who is a legally licensed doctor of dental surgery, dental medicine or dental science in the state where services are rendered and is acting within the scope of that license.

Dental Hygienist: A person who is licensed to practice dental hygiene in the state where services are rendered and is acting under the supervision and direction of a Dentist and within the scope of that license.

Dependent: An Insured Person's: 1. Lawful spouse; 2. Unmarried Child who is primarily dependent upon the Insured Person for support and maintenance and is: A. Less than 19 years of age; or B. Between 19 and 23 years of age; provided however, that the Child is dependent upon the Covered Person for support and maintenance and a full-time student actively attending an accredited college, vocational or high school. Full-time, as used in this definition, means actively attending at least 12 hours of class a week or, if less, attending the minimum hours of class the school considers as full-time status;

Dependent does not include anyone who:

•lives outside the United States;
•is in the armed forces of any country; or
•has coverage under the Policy as a Certificateholder or Dependent of another person.

Domestic Same-Sex Partners: Two same sex adults who are in a committed relationship and mutually responsible for one another financially and otherwise. To qualify as a Domestic Same Sex Partner, or Dependent under the Certificate, the following conditions must all be met:

•You and the Domestic Partner are over the age of 18 and mentally competent to enter into contracts;
•You and the Domestic Partner reside in the same household together;
•You and the Domestic Partner have a committed relationship with each other for no less than 6 months; intend to continue the relationship indefinitely and have no such relationship with any other person;
•You and the Domestic Partner are not related by blood;
•You and the Domestic Partner are not married to any third party;
•You and the Domestic Partner are of the same sex;
•You and the Domestic Partner are not claiming Dependent status for the primary reason of gaining insurance coverage under this Certificate.

Emergency: A dental condition characterized by the sudden onset of acute symptoms of sufficient severity that the absence of immediate dental attention could reasonably result in: • permanently placing the Covered Person’s health in jeopardy: • causing other serious dental or health consequences; or • causing serious impairment of dental function.

We will make the final determination as to whether or not a condition is an Emergency.

Experimental/Investigational: A drug, device or medical or dental care or treatment will be considered experimental/investigational if:

•The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;
•The informed consent document utilized with the drug, device, medical or dental care or treatment states or indicates that the drug, device, medical or dental care or treatment is part of a clinical trial, experimental phase or investigational phase or if such a consent document is required by law;
•The drug, device, dental care or treatment or the patient informed consent document utilized with the drug, device or medical or dental care or treatment was reviewed and approved by the treating facility’s Institutional Review Board or other body serving a similar function, or if federal or state law requires such review and approval; Reliable Evidence shows that the drug, device or medical or dental care or treatment is the subject of ongoing Phase I or Phase II clinical trials, is the research, experimental study or investigational arm of on-going Phase III clinical
•trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis; or
•Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device or medical or dental care or treatment is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis.

Reliable Evidence means only: published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility studying substantially the same drug, device or medical or dental care or treatment; or the written informed consent used by the treating facility or other facility studying substantially the same drug, device or medical or dental care or treatment. Covered Procedures will be considered in accordance with the drug, device or medical or dental care at the time the expense is incurred.

Family Member: A person who is related to a Covered Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother and stepsister), or Child.

In-Network Provider: A Dentist who is under contract with Us or Our subcontracted vendor.

Insured/Insured Person/Member: The individual named on the Schedule of Benefits as the Insured who has: (a) submitted an application for coverage on himself or herself, his or her Dependents, or both; (b) meets the eligibility and effective date provisions set forth in the Certificate evidencing coverage under the Policy; (c) is approved for coverage by Us; and (d) for whom all applicable premiums are paid, and therefore has coverage under the Policy.


Medically Necessary: A treatment, drug, device, procedure, supply or service that is necessary and appropriate for the diagnosis or treatment of a Covered Person’s condition in accordance with generally accepted standards of dental practice in the United States at the time it is provided.

A treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it:

•is Experimental/Investigational;
•is provided solely for education purposes or the convenience of the Covered Person, a Family Member, Dentist, Hospital or any other provider;
•exceeds in scope, duration, or intensity the level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment.
•is for maintenance or preventive care;
•could have been omitted without adversely affecting the person’s condition or the quality of dental care; or
•can be safely provided to the patient on a more cost effective basis or pursuant to a more conservative form of treatment.


The fact that a Dentist may prescribe, order, recommend, or approve a service, supply or level of care does not, of itself, make the treatment Medically Necessary or make the charge a Covered Charge under the Policy. We reserve the right to determine whether a service, supply or drug is Medically Necessary.

Out-of-Network Provider: A Dentist, located within the PPO Service Area, who is not under contract with Us or Our subcontracted vendor.

Policy: The contract providing the benefits described herein issued to the Policyholder.

Policyholder: Means the Group, in whose name the Policy is issued, as shown on the Schedule of Benefits. PPO Service Area: The geographical area in which We have arranged to provide PPO services to Covered Persons.

Preferred Provider Organization (PPO): A designated entity within the PPO Service Area under contract with Us or Our subcontracted vendors to provider certain services at a reduced reimbursement rate within a PPO Service Area. We or Our subcontracted vendors will contract with In-Network Providers to provide services covered by the Policy.

Prescription Drugs: Drugs which may only be dispensed by written prescription under Federal law, and approved for general use by the Food and Drug Administration.

Reasonable and Customary Charge: The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the Geographic Area in which the charge is incurred. The most common charge means the lesser of:

•the actual amount charged by the provider;
•the negotiated rate;
•the usual charge which would have been made by a provider (Dentist, Hospital, etc) for the same or a comparable professional services, drugs, procedures, devices, supplies or treatment within the same Geographic Area, as determined by Us.

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

We, Our, Us, The Company: Standard Security Life Insurance Company of New York. You, Your: The person named on the Schedule of Benefits as the Insured Person.


Who is the Administrator?
Health Plan Administrators, Inc. (HPA) is a fully licensed, full service Third Party Administrator servicing business worldwide. HPA provides state of the art industry leading insurance services.


Why buy from us?
HPA has provided innovative health care solutions for over 60 years, meeting the needs of our customers with integrity, creativity and value. We strive to provide the best possible insurance coverage in a cost effective manner.

HPA is a customer-driven company differentiating itself through knowledge and experience. We, in conjunction with our trusted insurance carriers and licensed agents, share a mutual desire to provide important benefits to our customers and to meet their needs in an innovative, hassle-free manner.

HPA has a professional team of customer support, marketing, underwriting, claims and compliance specialists. State-of-the-art computer systems and reporting capabilities allow HPA to provide superior service and flexibility to agent distributors and clients. Licensed and approved nationally, HPA has always met or exceeded all state-mandated requirements including financial security, surety bonds, insurance coverage, and licensing.

This website provides a brief description of the benefits, exclusions and other provisions of the Master Policy# SSL ADEN-POL 0606 issued to Communicating for America. For a complete listing, the Group Policy is available for inspection at the Policyholder’s offices. Benefits may vary in different states. Secure DentalOne may not be available in all states. All rights reserved. SSL Secure DentalOne Bro. 1-19-07