Federal and State Compliance and Policy Disclosures, Exclusions, and Limitations

Dental Insurance Plans

Dental Plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age, family size, geographic location (residential zip code) and plan design.

Rates are subject to change upon 30 days’ prior notice in AK, AL, AR, AZ, CO, CT, DC, DE, HI, IA, ID, IL, IN, KS, KY, MA, ME, MI, MN, MO, MT, ND, NE, NH, NJ, NM, NY, OH, OK, OR, PA, RI, SD, TN, UT, VT, WI and WY, 31 days’ prior notice in SC, 40 days’ prior notice in MD, 45 days’ prior notice in FL, 75 days’ prior notice in MS, and 60 days’ prior notice in CA, GA, NV, TX, VA and WV. In LA rates are guaranteed for the initial 12-months of coverage, except if due to addition of a newly covered person, a change in age or geographic location, or a change in policy coverage. Thereafter, rates are subject to change upon 45 days’ prior notice. In NC, dental rates are guaranteed for a 12-month period.

Dental plans apply waiting periods to covered basic (6-months), major (12-months) and orthodontic (12-months) dental care services. In ME, waiting periods are waived for Class II and Class III if under the age of 19. Waiting periods may vary by state. Refer to the policy or outline of coverage for details. Class IV Orthodontia waiting period cannot be waived. Dental plans do not apply waiting periods to covered preventive/diagnostic services and temporomandibular joint services in AR, NM, NV, MN and VT. Some covered services are determined by age: topical application of fluoride or sealant, space maintainers, and materials for crowns and bridges. If the plan covers replacement of teeth, there is no payment for replacement of teeth that are missing prior to coverage. In FL, LA, OH, VA and VT, payment limitation no longer applies after 12 months of continuous coverage. In NM, payment limitation no longer applies after 6 months of continuous coverage.  In MD and NY, payment limitation no longer applies after 12 months of continuous coverage. In NY, Temporomandibular Joint Dysfunction will be included to the extent that it is determined that such treatment is dental in nature and such treatment is regularly covered under the listed covered services.

Dental preferred provider insurance policies have exclusions, limitations, reduction of benefits and terms under which a policy may be continued in force or discontinued.

Form Series for Cigna Health and Life Insurance Company:

Cigna Dental Preventive, 1000 and 1500 plans: AL, CO, CT, DE, HI, IA, IL, MI, ND, WV and WY: HC-NOT11 et al., AK: HC-NOT53, AR: HC-NOT36 et al., AZ: INDDENTPOLAZ032017, CA: INDDENTPOLCA0713 et al., DC: HC-NOT42, et al., FL: HC-NOT15 et al., GA: INDDENPOLGA0317, ID: HC-NOT51 et al., IN: HC-NOT23, et al., KS: HC-NOT49 et al., KY: HC-NOT44, et al., LA: INDDENTPOLLA0713, MA: HC-NOT11, HC-NOT32 et al., ME: HC-NOT58, et al., MD:INDDENTPOLMD.PREV, INDDENTPOLMD.1000, INDDENTPOLMD.1500 and MDINDSADOHIPAMND10-20, MI: INDSADPOLMI.1000, INDENTPOLAMI042021.1500, INDENTPOLAMI042021.Prev, MO: INDDENTPOLMO0713, MN: INDDENTPOLMN0713, MS: HC-NOT48 et al., MT: INDDENTPOLMT0713, NC: HC-NOT18, NE HC-NOT47 et al., NH INDDENTPOLNH.1000, INDDENTPOLNH.1500, INDDENTPOLNH.PREV, NJ: HC-NOT46, et al., NM: INDDENPOLNM0322.1000 and INDDENPOLNM0322.1500, NY: INDDENTPOLNY.PREV, INDDENTPOLNY.1000, INDDENTPOLNY.1500, NV: HC-NOT39 et al., OH: INDDENTPOLOH0317, OK: HC-NOT26 et al., OR: INDDENTPOLOR0713, PA:INDDENPOLPA0917, RI: INDDENPOLRI0918., SC: HC-NOT19 et al., SD HC-NOT59 et al., TN: HC-NOT20 et al., TX: HC-NOT21 et al., UT: HC-NOT50 et al., VA: INDDENTPOLVA0317, VT HC-NOT56 et al., WA: INDDENTPOLWA0317, WI HC- NOT54 et al.)

Cigna Dental 5000/200, 3000/150, and 3000/100 plans: AL, CO, CT, DE, HI, IA, IL, ND, PA, WV and WY: HC-NOT11 et al., AK: HC-NOT53, et al., AR: HC-NOT36 et al., AZ: INDDENPOLAZ, CA: INDDENPOLCA, DC: HC-NOT42, et al., FL: HC-NOT15 et al., GA: INDDENPOLGAv1, ID: HC-NOT51 et al., IN: HC-NOT23, et al., KS: HC-NOT49 et al., KY: HC-NOT44, et al., LA: INDDENPOLLA, MA: HC-NOT11 et al., ME: INDDENPOLME, MI: INDDENPOLMI, MO: INDDENPOLMO, MS: HC-NOT48 et al., MT: INDDENPOLMT, NC: HC-NOT18, et al., NE HC-NOT47 et al., NH: INDDENPOLNH, NM: INDDENPOLNM, NJ: HC-NOT46, et al., NV: HC-NOT39 et al., OH: INDDENPOLOH, OK: HC-NOT26 et al., RI: INDDENPOLRI, SC: INDDENPOLSC1022, SD: HC-NOT59 et al., TN: HC-NOT20 et al., TX: HC-NOT21 et al., UT: HC-NOT50 et al., VA: INDDENPOLVA, VT: HC-NOT56 et al., WI: HC-NOT54 et al.

Cigna Dental Vision/Dental Vision Hearing: INDDVPOL[State]1021.1000, INDDVHPOL[State], 1021.2000, INDDVPOL[State]1021.2500R, INDDVHPOL[State], 1021.3500 (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NH, NJ, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, WV and WY).

The policy may be cancelled by Cigna due to failure to pay premium, fraud (in VA, any act, practice or omission that constitutes fraud), ineligibility, when the insured no longer lives in the service area, or if we cease to offer policies of this type or any individual dental plans in this state, in accordance with applicable law. You may cancel the policy, on the first of the month following our receipt of your written notice. In VA, you may cancel the policy on the date of our receipt of your written cancelation notice, unless otherwise stated. We reserve the right to modify this policy, including policy provisions, benefits and coverages, consistent with state or federal law. This individual plan is renewable monthly or quarterly.

Dental Pediatric Insurance Plans

Dental Plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates vary based on age, number of enrolled dependents, geographic location (residential zip code), and plan design.

These dental plans offer the full range of Essential Health Benefit Pediatric Oral Care and satisfy the requirements under the Affordable Care Act. This policy does not provide any dental benefits to individuals age nineteen (19) or older. This policy is being offered so the purchaser will have pediatric dental coverage as required by the Affordable Care Act. If you want adult dental benefits, you will need to buy a plan that has adult dental benefits. This plan will not pay for any adult dental care, so you will have to pay the full price of any care you receive.