CERTIFICATE OF COVERAGE - Paramount Health Care...CERTIFICATE OF COVERAGE Medicare Advantage Dental Plan Y0140_2020Dentalcoc_C PD MA OSB COC 2019 1 Paramount Dental Medicare Advantage

PARAMOUNT ELITE | ELEMENTS

DOT PATTERN FOR BACKGROUND

Paramount Elite has an HMO plan and a PPO plan each with a Medicare contract. Enrollment in Paramount Elite HMO or Paramount Elite PPO depends on contract renewal.

CERTIFICATE OF COVERAGE

Medicare Advantage Dental Plan

Y0140_2020Dentalcoc_C

PD MA OSB COC 2019 1

Paramount Dental Medicare Advantage Dental Plan

Medicare Advantage Supplemental Dental Plan

DENTAL ONLY CERTIFICATE OF COVERAGE

TABLE OF CONTENTS

Certificate of Coverage ................................................................. 2

How to Contact Us ....................................................................... 3

Eligibility – Initial, Open and Special Enrollment ........................... 3

Receiving Dental Care – Selection of Dentist ............................... 4

Accessing Your Benefits ............................................................... 4

How Payments are Made/Explanation of Benefits (EOB) ............. 4

Plan Features ............................................................................... 5

General Exclusions ...................................................................... 6

Coordination of Benefits ............................................................... 7

Grievance and Appeals ............................................................... 8

Termination of Coverage ............................................................ 10

General Conditions ..................................................................... 10

Fraud Hotline .............................................................................. 11

Definitions……………………….…………..…………………...……12

Schedule of Benefits including Limitations and Restrictions ....... 15

Online materials are available through our dedicated website portal – paramounthealthcare.com – and serve as the primary source of the most recent and up-to-date information. Any printed documents that you may have are based on information at a certain point in time and may not be inclusive of all benefits, restrictions and limitations.

NOTICE: IF YOU ARE COVERED BY MORE THAN ONE HEALTH CARE AND/OR DENTAL CARE PLAN, YOU MAY NOT BE ABLE TO COLLECT BENEFITS FROM BOTH PLANS. EACH PLAN MAY REQUIRE YOU TO FOLLOW ITS RULES OR USE SPECIFIC DENTISTS. IT MAY BE IMPOSSIBLE TO COMPLY WITH BOTH PLANS AT THE SAME TIME. READ ALL OF THE RULES VERY CAREFULLY, INCLUDING THE COORDINATION OF BENEFITS SECTION, AND COMPARE THEM WITH THE RULES OF ANY OTHER PLAN THAT COVERS YOU.

READ THIS CERTIFICATE CAREFULLY!


Welcome!

Thank you for choosing Paramount Dental to supplement your Paramount Elite Medicare Health Plan. Focused on prevention, this plan offers quality and cost-effective dental care. It also provides a wide, national network of quality dentists -- both generalists and specialists.

Your enrollment in this dental plan is contingent on your enrollment in a Paramount Elite Medicare Health Plan. Paramount Elite is an HMO/PPO plan with a Medicare contract.

We are committed to providing you with the highest quality member services. Our dedicated team is available to you via phone. You may also access information at paramounthealthcare.org.

It is your responsibility to understand your benefits and associated limitations and restrictions. Please read and save this certificate for your reference.

CERTIFICATE OF COVERAGE

Paramount Dental issues this Certificate of Coverage (referred to herein as certificate) to you, the member. The certificate is a summary of your dental benefits coverage and is a legal document between Paramount Dental (referred to herein as “we”, “us”, “our”) and you. Your coverage is subject to the terms, conditions, limitations and exclusions outlined in the certificate of coverage. The certificate reflects and is subject to the contract between Paramount Dental and Paramount Elite Medicare. Reasonable effort has been made for this certificate to represent the intent of the plan language between Paramount Elite Medicare and you.

We issue this certificate based on your application and payment of the required premium. You must be enrolled in a Paramount Elite Medicare contract to be eligible for this supplemental dental plan. In addition to this certificate, the policy includes the schedule of benefits. The benefits provided under this plan may change if any federal laws change. All the provisions in the following pages form a part of this document as fully as if they were stated over the signature below.

IN WITNESS WHEREOF, this certificate is executed by an authorized officer.

Sincerely,

Lori A. Johnston President, Paramount Health Care


HOW TO CONTACT US

By Mail

Paramount Dental c/o Paramount Elite Medicare P.O Box 928Toledo, Ohio 43697

By Phone

Please contact Paramount Elite Member Services at 419-887-2525 or toll free 1-800-462-3589 from 8 a.m. to 8p.m., Monday through Friday. From Oct. 1 through March 31, we are available 8 a.m. to 8 p.m., seven days perweek. TTY users should call 1-888-740-5670.

Online

You may also visit Paramount Dental online 24 hours a day, seven days a week at MyParamount.org. Heremembers can:

• Find a dentist who is in the Paramount Dental network

• Verify benefits, renewal dates, coverage and claimstatus

• Print member ID card

• Review benefit history

• Learn more about oral healthELIGIBILITY Enrollment and eligibility in this Paramount Dental Plan coincides with your Paramount Elite Medicare health plan guidelines as set below:

Open Enrollment Period – A set time each year when members in a Medicare Advantage plan, like Paramount Elite Medicare, can cancel their plan enrollment (health and dental) and/or switch to Original Medicare or make changes to your Part D coverage. The open enrollment period is from Jan. 1 until March 31 of each year.

Annual Election Period – A set time each fall when members can change their dental, health and/or drug plans or switch to Original Medicare. The annual enrollment period is from Oct. 15 until Dec. 7.

Initial Enrollment Period This is the period when you can sign up for Medicare Part A and Part B for the very first time. Your Initial Enrollment Period is the seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65.

Special Enrollment Period – A set time when members can change their dental, health and/or drug plans and/or return to Original Medicare. Situations in which you may be eligible for a special enrollment period include but are not limited to: moving outside the service area, getting “Extra Help” with your prescription drug costs, moving into a nursing home, or the plan violating its contract with you.

All Paramount Elite Medicare members are considered eligible to join the Paramount Dental supplemental dental plan. The member pays the full cost of dental plan. Dependents are not eligible. If at any time coverage is terminated, you may not re-enroll until the following annual election period. Benefits will cease on the last day of the month in which eligibility is terminated.


RECEIVING DENTAL CARE – SELECTION OF YOUR DENTIST

Dentistry is a highly personal service. The plan does not dictate what treatment you receive. Only you and your dentist can determine that. However, the plan does determine what services are covered and by what type of dentist. The plan pays for only those covered services listed in this booklet within the limitations and restrictions presented. You must personally pay for any service which is not covered or for any service that is covered but is subject to limitations and restrictions.

Under this in-network plan, you must receive care from a dentist who is a member of the Paramount Dental network to receive benefits. Benefits will be denied if you do not use an in-network dentist. An in-network dentist is a dentist who is contracted with the Paramount Dental Network or its leased dental network.

Our network includes more 190,000 locations nationwide, including specialists, who have agreed to accept discounts on your covered dental services. They have also agreed not to balance bill you for the difference between their fees charged and the contracted fee paid to them. Before enrolling in this dental plan, confirm if your dentist participates in the network and consider if you are willing to change to an in-network dental provider. In-network dentists are independent contractors and not employees of the plan.

Remember, this is an in-network only program. Visit the Find a Dentist link on paramounthealthcare.org to review a listing of Paramount Dental in-network dentists. When accessing Paramount Dental’s online directory, select the link labeled Medicare Advantage Network. Or, you may call Paramount Dental at 800-727-1444.

IMPORTANT: If you receive services from a dentist who does not participate in Paramount Dental’s Elite Medicare network, you will be responsible for the full amount charged for those services. No payment will be made by Paramount Dental.

ACCESSING YOUR BENEFITS

Please read this certificate and the schedule of benefits carefully so you are familiar with your benefits, payment methods, and terms of this plan.

When you make an appointment with a Paramount Dental dentist, let the office know that you have Paramount Dental, a supplemental dental plan through Paramount Elite Medicare. If your dentist is not familiar with this plan or network or has any questions, they should contact Paramount Dental by calling the toll-free number at 800-727-1444.

After you receive your dental treatment, your participating Paramount Dental provider will fill out and submit your dental claims (including supporting attachments) for you electronically (Payor ID CX019). They may also fax or mail claims to:

Paramount Dental P.O. Box 659 Evansville, IN 47704-0659 Fax: 812-401-3609

HOW PAYMENT FOR BENEFITS IS MADE – EXPLANATION OF BENEFITS (EOB)

Paramount Dental will make payments for covered services in accordance with this plan. Your plan is identified on your schedule of benefits within this certificate.

Once your dentist files a claim, Paramount Dental will decide within 30 days of receipt if it is a legitimate claim. If there is not enough information to approve your claim, Paramount Dental will notify you and your dentist within 30 days. The notice will describe the information needed, explain why it is needed and inform you and your dentist that the information must be received within 60 days or your claim will be denied. You will receive a copy of any notice sent to your dentist. Once we receive the requested information, your claim will be processed. If you or your dentist does not supply the requested information, we will deny your claim. Notification of denial will be sent to both you and your dentist.

Once we process your dental claim, you will receive an Explanation of Benefits explaining payment amounts. It is possible that your dentist’s charges for one or more of the procedures may be higher than the maximum allowed under your plan. If so, a contracted in-network dentist must reduce the charged amounts.


Paramount Dental will send payment directly to your dentist and you will be responsible for any applicable copayments or deductibles. Your in-network Paramount Dental provider will base payment on the maximum allowable charges for covered services. If you elect to receive services from a dentist who is not in the Paramount Dental network, you will be responsible for the full amount charged and Paramount Dental will make no payment.

If a claim is not received within one year of the date of service, the claim will not be considered for payment. This includes submitted claims for which we have not received the documentation from your dentist (federal W9 form, radiographs, narratives, etc., or unable to process due to incorrect filing information) required to determine and finalize the claim benefit.

Maximum Allowable Charges

Maximum allowable charges are the charges an in-network dentist agrees to accept for covered services. Maximum allowable charges apply to all covered services under a member’s benefit plan -- whether payable by the plan or the member.

Pre-Treatment Estimate

A pre-treatment estimate is for informational purposes only. It is not required before you receive dental care. Your claim will be processed after completion of the dental service. If you are not sure whether a particular dental treatment is covered or how much you will be required to pay, request a pre-treatment estimate from your dentist. It is a free service offered by Paramount Dental. The benefits estimate provided on a pre-treatment estimate notice is based on benefits available on the date the notice is issued. It is not a guarantee of future dental benefits or payment. We recommend requesting pre-treatment estimates for procedures requiring utilization review and procedures that require coinsurance/out-of-pocket costs.

Non-Covered Services

Unless prohibited by federal law, you will be responsible for the dentist’s submitted amount for services not covered by your plan. Services you receive from dentists who are not in Paramount Dental’s Medicare network are also considered non-covered benefits.

PLAN FEATURES

The benefits covered by this plan are set forth in your schedule of benefits and as summarized below.

Plan Annual Maximum Benefits/Plan Year

Benefits payable under the plan, regardless of whether coverage is continuous or not, will be subject to the plan annual maximum for each plan year. Payments under your certificate for ALL covered services apply to the plan annual maximum benefit. You will continue to pay maximum allowable charges and realize savings on all covered services after your annual maximum has been reached.

Deductible

The plan year deductible is applicable to non-preventive and diagnostic covered services incurred in each plan year. A benefit deductible is the amount a member must pay for covered services before the Paramount Dental will reimburse for those covered services. This amount may vary based upon the coinsurance of the covered service.

Example: (Fee Allowed - Deductible) x Coinsurance = Plan Payment

Patient receives major services covered at 50% under the plan. The member is responsible for a $25 individual deductible.

Waiting Period

The waiting period is the period of time beginning on the member’s effective date before benefits for certain covered service become eligible for reimbursement. Unless otherwise specified, the most recent effective date is utilized in the application of the waiting period. This includes a change to your dental plan coverage such as termination and reinstatement of coverage.


Limitations and Restrictions

Some services are limited by the age of the patient, how often the service may be performed, or specific teeth. All time intervals (frequency limitations) required by coverage are independent of calendar year or plan year. Frequency limitations regarding how often services may be performed are continuous. Change of dental plan coverage, termination and reinstatement of coverage does not eliminate the frequency limitations.

Utilization Review

Utilization review is the process by which a licensed dentist consultant for Paramount Dental reviews documentation (X-rays, charting, narratives, etc.) submitted by your dentist to determine if the service meets established criteria for payment by the plan. If a covered procedure requires utilization review, it will be noted in your certificate.

Alternate Benefits

Often, more than one service can be used to treat a dental problem or disease. In determining the benefits payable on a claim, different materials and methods of treatment will be considered. If applicable, the amount payable will be limited to the covered expense for the least costly service, which meets broadly accepted standards of dental care as determined by Paramount Dental. A member and his/her dentist may decide to use a more costly service or material that is satisfactory for the treatment of the condition. However, the plan payment will be limited to the least costly covered service for covered American Dental Association codes/expenses.

Unbundling

When charges are separated for less complicated services performed with a more comprehensive or extensive definitive treatment, the less complicated components may be considered as parts of the primary service. If the dentist bills separately for the primary service and each of its component parts, the total benefit payable for all related charges will be limited to the benefits payable for covered expenses for the primary service.

GENERAL EXCLUSIONS

The certificate issued is subject to the following general exclusions:

This certificate will not pay for dental services that are not listed in the schedule of benefits included withthis certificate.

This certificate will not pay claims for cosmetic dentistry for aesthetic reasons.

This certificate will not pay claims for dental services rendered before the effective date or after coverageis terminated.

This certificate will not pay claims for dental services covered under non-dental insurance.

This certificate will not pay claims for charges made by hospitals or prescription drugs ormedicaments/solutions.

This certificate will not pay claims for services performed primarily to rebuild occlusion or full mouthreconstruction.

This certificate will not pay claims for members until we receive the appropriate contracted payment(s) forpremiums.

This certificate will not pay claims for services which are not completed.

This certificate will not pay for duplicates, lost or stolen prostheses, appliances and/or radiographicimages.

This certificate will not pay claims received one year after the date of service.

Infection control/sterilization is not considered a separate billable procedure or service and cannot bebilled to a member or Paramount Dental.

All covered services will be considered in relation to the most global or comprehensive procedure and as such separate charges for procedural components may be denied or disallowed. This includes, but is not limited to,


separate charges for the use of local anesthetic, bonding agents, bases, pulp capping, etchants, etc.

COORDINATION OF BENEFITS

The Coordination of Benefits provision applies when a person has dental or healthcare coverage under more than one plan. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits.

The plan that pays first is called the primary plan. The primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses.

The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100% of the total allowable expense.

Terms

1. A plan is any of the following that provide benefits or services for medical or dental care or treatment. Ifseparate contracts are used to provide coordinated coverage for members of a group, the separatecontracts are considered parts of the same plan and there will be no Coordination of Benefits among theseparate contracts.

a. Plan includes: group and non-group insurance contracts, health maintenance organizationcontracts, closed panel plans or other forms of group or group-type coverage (whether insured oruninsured); medical care components of long-term care contracts, such as skilled nursing care;and Medicare or any other federal governmental plan, as permitted by law.

b. Plan does not include: hospital indemnity coverage or other fixed indemnity coverage; accident-only coverage; specified disease or specified accident coverage; limited benefit health coverage,as defined by state law; school accident type coverage; benefits for non-medical components oflong-term care policies; Medicare supplement policies; Medicaid policies; or coverage under otherfederal governmental plans, unless permitted by law.

2. Each contract for coverage under a. or b. is a separate plan. If a plan has two parts and Coordination ofBenefits rules apply only to one of the two, then each part is treated as a separate plan.

3. This plan means, in a Coordination of Benefits provision, the part of the contract providing the healthcarebenefits to which the Coordination of Benefits provision applies and which may be reduced because ofthe benefits of other plans. Any other part of the contract providing healthcare benefits is separate fromthis plan. A contract may apply one Coordination of Benefits provision to certain benefits, such as dentalbenefits, coordinating only with similar benefits and may apply another Coordination of Benefits provisionto coordinate other benefits.

4. Allowable expense is a healthcare expense, including deductibles, coinsurance and copayments, which isassociated with a covered service for which reimbursement is available or for which reimbursement wouldbe available but for the application of contractual limitations. When a plan provides benefits in the form ofservices, the reasonable cash value of each service will be considered an allowable expense and abenefit paid. An expense that is not covered by any plan covering the person is not an allowable expense.In addition, any expense that a provider by law or in accordance with a contractual agreement isprohibited from charging a covered person is not an allowable expense.

5. Benefit reserve is the savings recorded by a plan for claims paid for a covered person as a secondaryplan rather than as a primary plan.

Order of Benefit Determination Rules

When a person is covered by two or more plans, the rules for determining the order of benefit payments are as follows:

1. The primary plan pays or provides its benefits according to its terms of coverage and without regard tothe benefits of under any other plan.

2. A plan that does not contain a Coordination of Benefits provision that is consistent with this regulation isalways primary unless the provisions of both plans state that the complying plan is primary.


3. When a person is covered by two or more plans, the rules for determining the order of benefit paymentsare as follows:

a. This plan will pay primary over any Medicaid or retiree plan that you may have.

b. This plan will pay secondary to any employer sponsored, automobile, group or individual plan youmay have except for those listed above in a.

c. If this plan is the primary plan, it will pay its benefits according to its terms of coverage and withoutregard to the benefits under any other plan.

d. Except as provided in the following paragraph, a plan that does not contain a Coordination ofBenefits provision is always primary unless otherwise required by law.

e. If the preceding rules do not determine the order of benefits, the allowable expenses shall beshared equally between the plans meeting the definition of a plan. In addition, this plan will not paymore than it would have if it had been the primary plan.

4. Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of abasic package of benefits and provides that this supplementary coverage shall be excess to any otherparts of the plan provided by the contract holder, shall be secondary regardless of whether or not itcontains a Coordination of Benefits provision.

Effect on the Benefits of this Plan

When this plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all plans during a plan year are not more than the total allowable expenses. To determine the amount to be paid for any claim, the secondary plan will calculate the benefits it would have paid in the absence of other healthcare coverage and apply that calculated amount to any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may then reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not exceed the total allowable expense for that claim. In addition, the secondary plan will credit to its plan deductible any amounts it would have credited to its deductible in the absence of other healthcare coverage.

If a covered person is enrolled in two or more closed panel plans and if, for any reason, including the provision of service by a non-panel provider, benefits are not payable by one closed panel plan, Coordination of Benefits shall not apply between that plan and other closed panel plans.

If the amount of the payments made by this plan is more than it should have paid under this Coordination of Benefits provision, it may recover the excess from one or more of those paid.

Certain facts about healthcare coverage and services are needed to apply these Coordination of Benefits rules and to determine benefits payable under this plan and other plans. We may give information to or get information from other organizations or persons for the purpose of applying these rules and determining benefits payable under this plan and other plans covering the person claiming benefits. We need not tell or get the consent of any person to do this. Each person claiming benefits under this plan must give us any facts needed to apply those rules and determine benefits payable.

If you believe that we have not paid a claim properly, first try to resolve the problem by contacting us. Also, you may follow the Grievance and Appeals Procedure below.

GRIEVANCE AND APPEAL PROCEDURES

Notice

Your plan has been designed carefully to provide you with the maximum amount of covered benefits for your level of payment/premium. Because we are always looking for ways to make our plans and certificates better, your suggestions are encouraged. Occasionally, even after you have reviewed the applicable sections of this certificate pertaining to your issue at hand, you may have a question. Your questions may involve dentists, covered services, the agents who sold and service your plan, or our policies or procedures.

We must receive your grievance or appeal notice within 60 days after you received your Explanation of Benefits. Failure to give notice within this timeframe will not invalidate or reduce any claim if it can be shown that it was not


reasonably possible to give notice within the 60 days. However, such notice should always be given as soon as reasonably possible.

Informal Claims Appeal Procedure

We always notify you of a benefit determination after your claim is filed. This notice is made via an Explanation of Benefits. An adverse benefit determination is any denial, reduction or termination of the benefit for which you filed a claim or failed to provide or make payment (in whole or in part) of the benefit you sought. This includes a determination based on eligibility, the administration of covered services, limitations or restrictions, and payment amounts. If you receive notice of an adverse benefit determination and think that we incorrectly denied all or part of your claim, you may take the following steps:

First, you or your dentist should contact our Member Services team listed on page 3 of this certificate. Ask them to review the claim to make sure it was processed correctly. If you contact us in writing, please enclose a copy of your Explanation of Benefits and describe the problem. Sharing this information might indicate that your claim was improperly denied and allow us to correct this error quickly.

Formal Claims Appeal Procedure

You or your authorized representative may submit your claim to a formal review via the claims appeal procedure. To request a formal appeal of your claim, you must send your request in writing to the dental claims review team:

Dental Review Team c/o Paramount Dental P.O. Box 928 Toledo, Ohio 43697

Include your name and address, member ID number, the reason you believe your claim was wrongly denied, and any other information you believe supports your claim. This includes sections of certificate that support your appeal. If you would like a record of your request and proof that is was received by us, please use certified mail, return receipt requested.

You or your authorized representative should seek a review as soon as possible after you receive your Explanation of Benefits. However, you must file your appeal within 90 days of receiving your Explanation of Benefits.

Our dental claims review team will make their decision and notify you in writing within 30 days of receiving your request. Their notice of any adverse determination will:

a) Inform you of the specific reasons for the denial

b) List the pertinent certificate provision on which the denial is based

c) Contain a statement that you are entitled to receive upon request and at no cost, reasonable access toand copies of the documents, records and other information relevant to the decision to deny your claim.

Adverse appeals will be submitted automatically to the Medicare contracted independent review entity within 60 days from the date we received the member’s formal appeal. The appeals staff will concurrently notify the member that the appeal is being forwarded to the independent review entity of Centers for Medicare and Medicaid Services. The process for filing a grievance is also outlined in your Paramount Medicare Elite Evidence of Coverage. We respond in writing to all grievances within 30 days of receipt.

AUTHORIZED REPRESENTATIVE

You may appoint an authorized representative to deal with Paramount Dental on your behalf with respect to this certificate or to any benefit claim filed by your dentist. While in some circumstances, your dentist is treated as your authorized representative, generally Paramount Dental only recognizes the person whom you have authorized on the last dated form filed with Paramount Dental. If you have not designated a representative, Paramount Dental will only communicate with you. To request a form to designate the person you wish to appoint as your representative, call 800-727-1444 or write to us at P.O. Box 659, Evansville, IN 47704-0659. Or, you may use the Centers for Medicare and Medicaid Services Appointment of Representative Form (Form CMS-1696).


TERMINATION OF COVERAGE

Your dental coverage may be automatically terminated: • When your Paramount Medicare Elite health plan advises us to terminate your

coverage

• When you fail to pay timely dental premium payments to us

• For fraud or misrepresentation in the submission of any claim

• For any other reason stated in the certificate.A person whose Paramount Elite Medicare health plan eligibility is terminated may not continue coverage under this plan.

Voluntary Disenrollment

You can voluntarily disenroll from this optional dental benefit at any time during the contract year uponproper written notice to request disenrollment from the dental benefit. The disenrollment date will alwaysbe prospective and will be effective the first of the month following plan receipt of the written or faxeddisenrollment request.

You must submit a written request to terminate your optional dental coverage toParamount Health Care, P.O. Box 928, Toledo, OH 43697, Attention: Membership.

Or, you can fax your request to 419-291-9984.

Your request to cancel the dental benefit must be in writing. Please be very clear that you are onlyrequesting to cancel your dental supplemental benefit. If you are owed any premiums as a result ofcanceling this coverage, they will be credited to you on your next bill. Please remember if you are payingyour premiums through automatic deduction from your Social Security check, it may take two or moremonths for this change to begin.

Note: Once you have disenrolled from these dental benefits, you will not be able to re-enroll in thesupplemental dental benefit package until the next Annual Election Period (AEP).

GENERAL CONDITIONS

Entire Contract; Changes

The policy, including the endorsements, certificates, riders, application and the attached papers, if any, constitutes the entire contract of insurance. No change in the policy will be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions. We will consider any statement made by you, in the absence of fraud, as a representation and not a warranty. With 30 days of notice to you, we may amend coverage, limitations to the covered services, general exclusions, annual maximum, benefit payments or any other terms of this certificate or the plan.

Claim Forms

Your in-network dentist will file your claim. If for some reason your in-network dentist refuses to file your claim, please contact us. However, it is ultimately your responsibility to request this from your dentist and verify that the dentist has performed the filing.

Time of Payment of Claims

Benefits for services covered by the policy will be paid when we receive all information necessary, including premium payment, to correctly adjudicate the claim, but not more than 30 days after receipt of all necessary information.

If we fail to pay or deny a clean claim in the time required and subsequently pay the claim, we may pay the provider who submitted the claim interest on the allowable amount of the claim.


Legal Actions

A legal action may not be brought against us before 60 days or after three years from the date written proof of loss is required to be given.

Right of Recovery

Whenever payments have been made in excess of the amount due under the plan, we have the right, exercisable alone and in its sole discretion, to recover excess payments from one or more of the persons we have paid or for whom it has paid or any other person or organization that may be responsible for the benefits or services provided for the covered person.

Governing Law

This certificate and the underlying group contract will be governed by and interpreted under Centers for Medicare and Medicaid Services. If any provisions of the plan are contrary to any law to which it is subject, such provision will be amended to conform to the minimum extent necessary to satisfy legal requirements.

Legally Mandated Benefits

If any applicable law requires broader coverage or more favorable treatment for you than is provided by this certificate, that law shall control over the language of this certificate.

Miscellaneous

Section titles are for convenience of reference only and are not to be considered as interpretation of the plan. No failure to enforce any provision of the plan shall affect the right thereafter to enforce such provision, nor shall such failure affect its right to enforce any other provision of the plan.

FRAUD HOTLINE

Any person intending to deceive an insurer, who knowingly submits an application or files a claim containing a false or misleading statement is guilty of insurance fraud. Insurance fraud significantly increased the cost of health care. If you are aware of any false information, please call our toll-free hotline at 1-800-807-2693.


Definitions

Adverse Determination

Any denial, reduction or termination, or a failure to provide or to make payment (in whole or part) of the benefit sought. Such determination could be based on eligibility, application of any utilization review criteria, Plan limitations or restrictions or for non-covered services.

Allowable Amount/Expense

The maximum amount of reimbursement the plan will pay for covered dental services provided by an in-network dentist to a member and which meets our definitions of a covered service. The maximum allowable/expense is determined by a) the lesser fee of the primary or secondary insurance carrier as it applies to network participation, associated agreed discounts and patient responsibility or b) the fee considered for the global service. For in-network dentists, this is the dollar amount that the attending in-network dentist has agreed to accept as payment in full for the plan and the patient. This amount is shown on the notice that accompanies payment of the claim.

Balance Billing In-network dentists agree to accept the network’s contracted fees as payment in full. A participating dentist has agreed to not bill the patient for the difference between his fee charged and the contracted maximum allowable fee. This is referred to as “balance billing” and is not enforceable for an out-of-network dentist as they are under no obligation to limit their fees.

Benefits The amounts that the plan pays for covered services under a member’s dental plan.

Certificate This document. Benefits are provided as described in this certificate.

Claim/Claim Form Standard statement of dental services performed that is submitted by an in-network dentist or member to request payment from the payor. In-network dentists always file claim forms on behalf of members and accept payment directly from the payor. Claim forms are also used to request a pre-treatment estimate.

Coinsurance The member’s share, expressed as a fixed percentage, of the covered dental service.

Coordination of Benefits (COB)

A process that carriers use to determine the order of payment and amount each carrier will pay when a person receives dental services that are covered by more than one benefit plan. COB ensures that no more than 100 percent of the lowest allowable charges for services are paid when a member has coverage under two or more benefits plans (dual coverage).

Covered Services Dental care services for which a reimbursement is available under a member’s plan contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.

Deductible The amount a member must pay toward covered services before the plan begins paying for those services under this certificate.

Deny/Denied If a service is denied, the service is not considered a benefit of the patient’s coverage and the dentist’s services are collectible.


Disallow(ed) If a service is disallowed, the fee is not collectible from the patient by an in-network dentist.

Effective Date The date a dental benefits policy begins. Effective date may also be used to describe the date that benefits begin for a member. The effective date is determined in accordance with waiting periods and plan terms enforced by Medicare and applicable State and Federal regulatory entities.

Eligibility The circumstances or conditions determined by your plan that define who and when a person may qualify to enroll in a plan and/or a specific category of covered services. The eligibility guidelines are outlined in the certificate and in your Paramount Medicare Elite health plan Evidence of Coverage.

Eligible Member An eligible member who has met the eligibility requirements set forth by the plan.

Exclusions Services that are not covered under the plan.

Explanation of Benefits (EOB)

The statement received after a claim is processed, detailing how your claim was processed, including identification of services rendered, fees, application of plan limitations, calculation of plan payment, and the amount for which you are responsible.

Fee Charged The amount that the dentist bills and is entered on a claim as the charge for a specific service.

Limitations A list of conditions or circumstances that limit or exclude services from plan coverage. Limitations may be related to time or frequency (the number of services permitted during a stated period).

Plan The dental coverage established for you pursuant to this certificate.

Plan Annual Maximum Benefit

The total maximum dollar amount the plan will pay toward the cost of dental care incurred by an individual member in a plan year.

Member A person covered under the plan.

In-Network Dentist A dentist who contracts with us or leased network carrier and agrees to accept contracted fees as payment in full and abide by certain administrative guidelines.

Network A panel of dentists that contractually agrees to provide treatment according to administrative guidelines, including limits to the fees accepted as payment in full.

Open Enrollment A period of time when you can enroll or change your plan coverage. This is determined by Paramount Elite and Paramount Dental.

Out-of-Network A dentist who does not contract with us to participate in our network and the associated administrative guidelines including claim submission requirements and maximum allowable fee capitations.

Patient Responsibility

The portion of a dentist’s fee that a member must pay for dental services, including deductible, coinsurance, any amount over plan maximums, services the plan does not cover and covered services for which the patient is not eligible.


Pre- Authorization A requirement that recommended treatment must first be approved by the plan before the treatment is rendered in order for the plan to pay benefits for those covered services.

Premiums The money billed and paid to us for each month of dental coverage. Payment must be made by you in order for claims to be paid.

Pre-Treatment Estimate

A non-binding estimate of the benefits available and patient responsibility for a proposed treatment plan after the application of plan limitations, restrictions, and exclusions, remaining plan annual maximum and determination of covered services.

Resin/ Composite Tooth-colored filling material. Although cosmetically superior, it is less durable than other materials.

Utilization Review The process by which a dental review team member reviews the required documentation (X-ray, perio chart, narrative) submitted with the procedure and determines if criteria have been satisfied to pay the benefit.

Waiting period Waiting periods are designated by us. If we establish a plan waiting period, it is the stated period of time that a member must be enrolled in the plan before being eligible for benefits or for a specific category of benefits.


Paramount Dental Medicare Advantage Plan – Optional Supplemental Schedule of Benefits

Includes Plan Covered Services, Percentage Covered and Limitations

ADA Code Service Description In Network / Out of Network %

D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED 100 / 0

D0180 COMPREHENSIVE PERIODONTAL EVALUATION-NEW OR ESTABLISHED PATIENT 100 / 0

D0210 INTRAORAL-COMPLETE SERIES OF RADIOGRAPHIC IMAGES 100 / 0

D1206 TOPICAL APPLICATION OF FLUORIDE VARNISH 100 / 0

D1208 TOPICAL APPLICATION OF FLUORIDE- EXCLUDING VARNISH 100 / 0

D2140 AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT 70 / 0

D2150 AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT 70 / 0

D2160 AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT 70 / 0

D2161 AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT 70 / 0

D2330 RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR 70 / 0

D2331 RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR 70 / 0

D2332 RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR 70 / 0

D2335 RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR)

70 / 0

D2391 RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR 70 / 0

D2392 RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR 70 / 0

D2393 RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR 70 / 0

D2394 RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR 70 / 0

D2740 CROWN-PORCELAIN/CERAMIC SUBSTRATE 50 / 0

D2750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL 50 / 0

D2752 CROWN-PORCELAIN FUSED TO NOBLE METAL 50 / 0

D2920 RE-CEMENT OR RE-BOND CROWN 70 / 0

D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION) 70 / 0

D3320 ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL RESTORATION) 70 / 0

D3330 ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION) 70 / 0

D4341 PERIODONTAL SCALING AND ROOT PLANING-FOUR OR MORE TEETH PER QUADRANT (4 TEETH WITH 4+MM POCKETS)

70 / 0

D5510 REPAIR BROKEN COMPLETE DENTURE BASE 70 / 0

D5520 REPLACE MISSING OR BROKEN TEETH-COMPLETE DENTURE (EACH TOOTH) 70 / 0

D5610 REPAIR RESIN DENTURE BASE 70 / 0

D5620 REPAIR CAST FRAMEWORK 70 / 0

D5640 REPLACE BROKEN TEETH-PER TOOTH 70 / 0

D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE 70 / 0

D5660 ADD CLASP TO EXISTING PARTIAL DENTURE PER TOOTH 70 / 0

D5730 RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) 70 / 0

D5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) 70 / 0

D5741 RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) 70 / 0

D5750 RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) 70 / 0

D5751 RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) 70 / 0

D5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) 70 / 0

D6930 RE-CEMENT OR RE-BOND FIXED PARTIAL DENTURE 70 / 0

D7111 EXTRACTION, CORONAL REMNANTS-DECIDUOUS TOOTH 70 / 0

D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL)

70 / 0

D7286 INCISIONAL BIOPSY OF ORAL TISSUE-SOFT 100 / 0

D9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN-MINOR PROCEDURE 100 / 0


Paramount Dental Medicare Advantage Plan – Optional Supplemental Schedule of Benefits – Limitations and Restrictions

(Including provider/utilization review and supporting documentation requirements)

ADA Code Limitations and Restrictions / Processing Policy

D0140

An evaluation limited to a specific oral health problem or complaint. The use of this procedure code is also appropriate in dental emergencies, trauma, acute infection, etc. Evaluations – not eligible for more than two evaluations, of any procedure code combination, within any consecutive 12 month period. These evaluations do not duplicate or add to preventive evaluations covered in your preventive dental benefit.

D0180

Eligible only once every 4 years. D0180 applies to age 14 and above. Charges will be disallowed if performed on the same date of service as D4355 (non-covered procedure). Evaluations – not eligible for more than two evaluations, of any procedure code combination, within any consecutive 12 month period. These evaluations do not duplicate or add to preventive evaluations covered in your preventive dental benefit.

D0210

A complete series includes bitewings. Eligible only once per 4 years. If D0210 is performed within 12 months of D0270, D0272, D0273, D0274 the allowable amount for D0210 will be reduced by the charges for D0270, D0272, D0273, D0274. The maximum amount considered for all radiographic images taken on one day will be equivalent to an allowance of a D0210. The difference may not be billed to the enrollee.

D1206 Eligible only for children under 14 years of age and only once per 6 months.

D1208 Eligible only once per 6 months up to age 19 only.

D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394

Not eligible for the replacement of or an additional restoration on the same surface for a period of 3 years. Not eligible if performed within 3 years of placing a crown on the same tooth or a sealant on the same surface within 3 years. If two or more restorations are performed on the same tooth, on the same date of service, only the total number of unique surfaces will be considered.

D2740, D2750, D2752

Not eligible for a replacement of any type of crown for 7 years. A charge for a crown following the placement of a restoration is not eligible for a period of 3 years. Utilization Review is required. Requires either the submission of a duplicate, diagnostically acceptable, pre-operative radiograph or intraoral photos that substantiates completion of root canal therapy or a narrative which addresses the existence of caries or other pathology, cracked tooth syndrome, missing cusp(s), the amount of remaining tooth structure or the amount of circumferential decay.

D2920 Not eligible for the re-cementation of a crown within 12 months of the original cementation. Eligible once per 12 months.

D3310, D3320, D3330

Eligible for a maximum of one procedure per tooth per lifetime.

D4341

Eligible per quadrant (4 or more active periodontal diseased and qualified teeth). The enrollee must exhibit periodontal disease showing loss of clinical attachment and bone loss. Not eligible for retreatment of any quadrant for 3 years. Utilization Review is required. Charges require the submission of full mouth probe chart with six points per tooth probings AND diagnostic full mouth radiographs and/or vertical bitewings. Only two quadrants are considered on the same date of service, additional quadrants will be disallowed. Separate charges for local anesthetic are disallowed. A D1110 cannot be charged within 6 months if four quadrants of D4341 are performed. Charges not meeting established criteria will be disallowed. A pretreatment is suggested.

D5510, D5520, D5610, D5620, D5640, D5650,

Eligible once per procedure code per 6 months.


D5660

D5730, D5740, D5741, D5750, D5751, D5760

Eligible only once per 4 years.

D6930 Eligible only once per 12 months.

D7111 Maximum of one procedure per lifetime per tooth.

D7140 Maximum of one procedure per lifetime per tooth.

D7286 Charges will be disallowed if performed in conjunction with D3410, D3421, D3425, D3426, or D3427.

D9110 Not eligible for more than two palliative (emergency) treatments per 12 month period. Charges filed in conjunction with definitive treatment will be disallowed.

Multi-Language Interpreter Services

English ATTENTION: If you speak English, languageassistance services, free of charge, are available to you. Call 1-800-462-3589 (TTY: 1-888-740-5670).

Albanian: KUJDES: Nëse flitni shqip, për ju ka nëdispozicion shërbime të asistencës gjuhësore, papagesë. Telefononi në 1-800-462-3589 (TTY: 1-888-740-5670).

Arabic: ةدعاسملاتامدخنإف،ةغللاركذاثدحتتتنكاذإ:ةظوحلمفتاھمقر(9853-264-008-1مقرب لصتا.ناجملاب كلرفاوتتةیوغللا

.)0765-047-888-1:مكبلاو مصلا

Bengali: ল"# ক%নঃ যিদ আপিন বাংলা, কথা বলেত পােরন, তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল< আেছ। >ফানক%ন ১-800-462-3589 (TTY: ১-888-740-5670)।

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 1-800-462-3589 (TTY：1-888-740-5670）。

Cushite: XIYYEEFFANNAA: Afaan dubbattuOroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-462-3589 (TTY: 1-888-740-5670).

Dutch: AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel1-800-462-3589 (TTY: 1-888-740-5670).

French: ATTENTION : Si vous parlez français, desservices d'aide linguistique vous sont proposésgratuitement. Appelez le 1-800-462-3589 (ATS : 1-888-740-5670).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-462-3589 (TTY: 1-888-740-5670).

Italian: ATTENZIONE: In caso la lingua parlata sial'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-462-3589 (TTY: 1-888-740-5670).

Japanese:注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-462-3589 （TTY:1-888-740-5670）まで、お電話にてご連絡ください。

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-462-3589 (TTY: 1-888-740-5670) 번으로 전화해 주십시오. Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-462-3589 (TTY: 1-888-740-5670). Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-462-3589 (TTY: 1-888-740-5670). Romanian: ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-462-3589 (TTY: 1-888-740-5670). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-462-3589 (телетайп: 1-888-740-5670). Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-462-3589 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-888-740-5670). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-462-3589 (TTY: 1-888-740-5670). Syriac: )ܵ'ܵܪܿܘܬܵܐ ، )ܸ+ܵ,ܵ( ܢܿܘ0ܸ/1ܼ2/ܼܿܗ 4ܹ( ܢܿܘ62ܼܿܐ ܢܸܐ 8ܵܪܵܗܼܘܙ :

DܼܿE ܢܿܘ@; .A=ܸ+ܵ,ܵ( /ܼܿBܵ,ܵC'ܼ2 ?ܵܬ@ܼܿ'ܼܿܗܕ ?2ܹܼܼܿܿ;ܕ ܢܿܘ2ܼ'9ܵ//ܸ,1ܵ,ܵ( 1-800-462-3589 (TTY: 1-888-740-5670)

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-462-3589 (TTY: 1-888-740-5670). Ukrainian: УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-462-3589 (телетайп: 1-888-740-5670). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-462-3589 (TTY: 1-888-740-5670).


English ATTENTION: If you speak English, languageassistance services, free of charge, are available to you. Call 1-800-462-3589 (TTY: 1-888-740-5670).

Albanian: KUJDES: Nëse flitni shqip, për ju ka nëdispozicion shërbime të asistencës gjuhësore, papagesë. Telefononi në 1-800-462-3589 (TTY: 1-888-740-5670).

Arabic: ةدعاسملاتامدخنإف،ةغللاركذاثدحتتتنكاذإ:ةظوحلمفتاھمقر(9853-264-008-1مقرب لصتا.ناجملاب كلرفاوتتةیوغللا

.)0765-047-888-1:مكبلاو مصلا

Bengali: ল"# ক%নঃ যিদ আপিন বাংলা, কথা বলেত পােরন, তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল< আেছ। >ফানক%ন ১-800-462-3589 (TTY: ১-888-740-5670)।

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 1-800-462-3589 (TTY：1-888-740-5670）。

Cushite: XIYYEEFFANNAA: Afaan dubbattuOroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-462-3589 (TTY: 1-888-740-5670).

Dutch: AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel1-800-462-3589 (TTY: 1-888-740-5670).

French: ATTENTION : Si vous parlez français, desservices d'aide linguistique vous sont proposésgratuitement. Appelez le 1-800-462-3589 (ATS : 1-888-740-5670).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-462-3589 (TTY: 1-888-740-5670).

Italian: ATTENZIONE: In caso la lingua parlata sial'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-462-3589 (TTY: 1-888-740-5670).

Japanese:注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-462-3589 （TTY:1-888-740-5670）まで、お電話にてご連絡ください。

Korean:주의: 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-800-462-3589 (TTY: 1-888-740-5670)번으로전화해주십시오.

Wann du [Deitsch (Pennsylvania German / Dutch)]schwetzscht, kannscht du mitaus Koschte ebbergricke, ass dihr helft mit die englisch Schprooch. Rufselli Nummer uff: Call 1-800-462-3589 (TTY: 1-888-740-5670).

Polish: UWAGA: Jeżeli mówisz po polsku, możeszskorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-462-3589 (TTY: 1-888-740-5670).

Romanian: ATENȚIE: Dacă vorbiți limba română, văstau la dispoziție servicii de asistență lingvistică,gratuit. Sunați la 1-800-462-3589 (TTY: 1-888-740-5670).

Russian: ВНИМАНИЕ: Если вы говорите нарусском языке, то вам доступны бесплатные услугиперевода. Звоните 1-800-462-3589 (телетайп: 1-888-740-5670).

Serbo-Croatian: OBAVJEŠTENJE: Ako govoritesrpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-462-3589 (TTY-Telefon za osobe sa oštećenim govorom ili sluhom:1-888-740-5670).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.Llame al 1-800-462-3589 (TTY: 1-888-740-5670).

Syriac: )ܵ'ܵܪܿܘܬܵܐ ، )ܸ+ܵ,ܵ( ܢܿܘ0ܸ/1ܼ2/ܼܿܗ 4ܹ( ܢܿܘ62ܼܿܐ ܢܸܐ : 8ܵܪܵܗܼܘܙDܼܿEܢܿܘ@; .A=ܸ+ܵ,ܵ(/ܼܿBܵ,ܵC'ܼ2?ܵܬ@ܼܿ'ܼܿܗܕ?2ܹܼܼܿܿ;ܕܢܿܘ2ܼ'9ܵ/

/ܸ,1ܵ,ܵ( 1-800-462-3589 (TTY: 1-888-740-5670)

Tagalog: PAUNAWA: Kung nagsasalita ka ngTagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa1-800-462-3589 (TTY: 1-888-740-5670).

Ukrainian: УВАГА! Якщо ви розмовляєтеукраїнською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-462-3589(телетайп: 1-888-740-5670).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có cácdịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-462-3589 (TTY: 1-888-740-5670).


English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-462-3589 (TTY: 1-888-740-5670). Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-462-3589 (TTY: 1-888-740-5670). Arabic: ةدعاسملا تامدخ نإف ،ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم

فتاھ مقر( 9853-264-008-1 مقرب لصتا .ناجملاب كل رفاوتت ةیوغللا.)0765-047-888-1 :مكبلاو مصلا

Bengali: ল"# ক%নঃ যিদ আপিন বাংলা, কথা বলেত পােরন, তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল< আেছ। >ফানক%ন ১-800-462-3589 (TTY: ১-888-740-5670)। 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 1-800-462-3589 (TTY：1-888-740-5670）。 Cushite: XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-462-3589 (TTY: 1-888-740-5670). Dutch: AANDACHT: Als u nederlands spreekt, kunt ugratis gebruikmaken van de taalkundige diensten. Bel 1-800-462-3589 (TTY: 1-888-740-5670). French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-462-3589 (ATS : 1-888-740-5670). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-462-3589 (TTY: 1-888-740-5670). Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-462-3589 (TTY: 1-888-740-5670). Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-462-3589 （TTY:1-888-740-5670）まで、お電話にてご連絡ください。

Korean:주의: 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-800-462-3589 (TTY: 1-888-740-5670)번으로전화해주십시오.

Wann du [Deitsch (Pennsylvania German / Dutch)]schwetzscht, kannscht du mitaus Koschte ebbergricke, ass dihr helft mit die englisch Schprooch. Rufselli Nummer uff: Call 1-800-462-3589 (TTY: 1-888-740-5670).

Polish: UWAGA: Jeżeli mówisz po polsku, możeszskorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-462-3589 (TTY: 1-888-740-5670).

Romanian: ATENȚIE: Dacă vorbiți limba română, văstau la dispoziție servicii de asistență lingvistică,gratuit. Sunați la 1-800-462-3589 (TTY: 1-888-740-5670).

Russian: ВНИМАНИЕ: Если вы говорите нарусском языке, то вам доступны бесплатные услугиперевода. Звоните 1-800-462-3589 (телетайп: 1-888-740-5670).

Serbo-Croatian: OBAVJEŠTENJE: Ako govoritesrpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-462-3589 (TTY-Telefon za osobe sa oštećenim govorom ili sluhom:1-888-740-5670).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.Llame al 1-800-462-3589 (TTY: 1-888-740-5670).

Syriac: )ܵ'ܵܪܿܘܬܵܐ ، )ܸ+ܵ,ܵ( ܢܿܘ0ܸ/1ܼ2/ܼܿܗ 4ܹ( ܢܿܘ62ܼܿܐ ܢܸܐ : 8ܵܪܵܗܼܘܙDܼܿEܢܿܘ@; .A=ܸ+ܵ,ܵ(/ܼܿBܵ,ܵC'ܼ2?ܵܬ@ܼܿ'ܼܿܗܕ?2ܹܼܼܿܿ;ܕܢܿܘ2ܼ'9ܵ/

/ܸ,1ܵ,ܵ( 1-800-462-3589 (TTY: 1-888-740-5670)

Tagalog: PAUNAWA: Kung nagsasalita ka ngTagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa1-800-462-3589 (TTY: 1-888-740-5670).

Ukrainian: УВАГА! Якщо ви розмовляєтеукраїнською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-462-3589(телетайп: 1-888-740-5670).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có cácdịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-462-3589 (TTY: 1-888-740-5670).

Notice of Nondiscrimination and Accessibility: Discrimination is Against the Law

Paramount Elite (HMO) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Paramount Elite does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Paramount Elite:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, other

formats)

• Provides free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languages

If you need these services, contact Paramount Elite Member Services at 1-800-462-3589 or, for TTY users, 1-888-740-5670, 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 through March 31, we areavailable 8:00 a.m. to 8:00 p.m. seven days per week.

If you believe that Paramount Elite has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. You can file a grievance in person or by mail, fax, or email.

Paramount Elite Member Services 1901 Indian Wood Circle, Maumee, OH 43537 Phone: 419-887-2525 Toll Free: 1-800-462-3589 TTY: 1-888-740-5670 Fax: 419-887-2047 Email: [email protected]

If you need help filing a grievance, Paramount Elite Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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