The governing legal instrument for every plan Denta administers. It is identical for every Employer; the terms that vary are elected in that Employer's Adoption Agreement. Delivered as a PDF after onboarding.

Denta Dental Plan — Base Plan Document

1. Establishment

1.1 An Employer establishes a dental benefits plan (the "Plan") by executing an Adoption Agreement that adopts this Base Plan Document. Together they are the written instrument required by ERISA §402(a)(1).

1.2 The Plan is a self-funded employee welfare benefit plan providing dental benefits. It is intended to be an excepted benefit under ERISA §733(c), Internal Revenue Code §9831, and Public Health Service Act §2791.

1.3 Where this document and an Adoption Agreement conflict, the Adoption Agreement governs as to the terms it elects and this document governs as to everything else.

2. Definitions

"Adoption Agreement" — the document by which an Employer adopts this Base Plan Document and records its elections.

"Annual Maximum" — the amount elected in the Adoption Agreement, available to each Covered Person in each Plan Year.

"Administrator" — Denta, Inc., engaged by the Employer under an Administrative Services Agreement to perform administrative and ministerial functions.

"Covered Person" — a Participant or, where the Employer has elected dependent coverage, a Dependent.

"Covered Service" — a service listed in Section 4 and not excluded by Section 5.

"Dependent" — a Participant's spouse or domestic partner, and a Participant's child up to age 26. Child includes a biological child, adopted child or child placed for adoption, stepchild, and a child for whom the Participant has legal guardianship.

"Employer" — the entity that executed the Adoption Agreement. The Employer is the Plan Sponsor, the Plan Administrator, and the Named Fiduciary.

"Participant" — an employee who has met the eligibility conditions in Section 3 and whose coverage has begun and not ended.

"Plan Year" — the calendar year. The first Plan Year is a short year running from the effective date elected in the Adoption Agreement through 31 December of that year.

3. Eligibility and participation

3.1 An employee is eligible if they are actively employed by the Employer and regularly scheduled to work at least the number of hours per week elected in the Adoption Agreement.

3.2 Coverage begins on the first day of the calendar month following the employee's date of hire, unless the Adoption Agreement elects a waiting period, in which case it begins on the first day of the calendar month following the end of that period.

3.3 Where the Employer has elected dependent coverage, a Dependent's coverage begins on the later of the Participant's coverage start date or the date the person becomes a Dependent.

3.4 Coverage ends on the earliest of: the last day of the calendar month in which employment ends; the last day of the calendar month in which the employee stops meeting Section 3.1; the date the Plan terminates; or, for a Dependent, the last day of the calendar month in which they stop being a Dependent.

3.5 Coverage ending does not affect a claim for a Covered Service furnished before coverage ended, provided the claim is filed within the deadline in Section 6.2.

3.6 Continuation of coverage under COBRA is governed by Section 10.

4. Benefits

4.1 Annual Maximum. The Plan pays for Covered Services furnished to a Covered Person up to the Annual Maximum in each Plan Year. The Annual Maximum applies separately to each Covered Person.

4.2 No proration. The Annual Maximum is the same in every Plan Year, including a short first Plan Year, and is not reduced for a partial year of coverage.

4.3 No carryover. An unused Annual Maximum does not carry over to the next Plan Year.

4.4 Covered Services. Services furnished by a licensed dentist and billed under the following CDT code ranges:

• D0100–D0999, diagnostic
• D1000–D1999, preventive
• D2000–D2999, restorative
• D3000–D3999, endodontics
• D4000–D4999, periodontics
• D5000–D5899, removable prosthodontics
• D6000–D6999, implants and fixed prosthodontics
• D7000–D7999, oral and maxillofacial surgery
• D8000–D8999, orthodontics

4.5 Amount paid. The Plan pays the amount the dentist charges for a Covered Service, up to the Annual Maximum.

4.6 Choice of dentist. A Covered Person may obtain Covered Services from any licensed dentist. The benefit does not change based on which dentist they choose.

4.7 Contracted rates. Where the Plan has agreed rates with a dentist, those rates are the amount charged, so the Annual Maximum covers more care. This affects the price of a service and not the level of benefit, and a Covered Person is not billed for the balance of a charge for a Covered Service at a contracted dentist.

4.8 Coordination with other coverage. Where a Covered Person has other dental coverage, the Plan pays the portion of the charge that the other coverage does not pay, up to the Annual Maximum. Total payments from all sources will not exceed the amount charged.

5. Exclusions

The Plan does not pay for:

5.1 Bleaching and whitening, CDT codes D9972 through D9975.

5.2 Veneers, contouring, and other services performed for cosmetic rather than functional purposes.

5.3 Any amount above the Annual Maximum.

5.4 Services furnished before coverage began or after coverage ended.

5.5 Services for which no charge is made, or which are furnished by an immediate family member of the Covered Person.

5.6 Services required as a result of war or an act of war.

5.7 Services payable under a workers' compensation or occupational disease law.

6. Claims

6.1 How to claim. A dentist may submit a claim to the Administrator directly, or a Covered Person may submit one for a service they have paid for.

6.2 Filing deadline. A claim must be filed within 12 months of the date of service. A claim filed after that is not payable, except where the claimant was legally incapacitated.

6.3 Post-service claims. The Administrator will decide a post-service claim within 30 days of receiving it. That period may be extended once, by up to 15 days, for matters beyond the Plan's control, with notice before the first period ends. Where the extension is because information is missing, the notice will say what is needed and the claimant has at least 45 days to supply it.

6.4 Pre-service claims. Where a Covered Person requests a predetermination before treatment, the Administrator will respond within 15 days, extendable once by up to 15 days. A predetermination is an estimate of what the Plan would pay, not a guarantee of payment.

6.5 Notice of an adverse determination. A notice denying a claim in whole or in part will state the specific reason, refer to the Plan provisions relied on, describe any additional information needed and why, and describe the appeal procedure and the right to bring a civil action under ERISA §502(a).

7. Appeals

7.1 A claimant may appeal an adverse determination within 180 days of receiving notice of it.

7.2 The claimant may submit written comments, documents, and other information, and on request will be given reasonable access, free of charge, to all documents and records relevant to the claim.

7.3 The Employer, as Named Fiduciary, decides the appeal. The review takes account of all information submitted, whether or not it was considered initially, and does not defer to the original determination. The person deciding the appeal is not the person who made the original determination, nor their subordinate.

7.4 The Employer will decide the appeal within 60 days of receiving it and will notify the claimant of the decision, the reasons for it, the Plan provisions relied on, and the right to bring a civil action under ERISA §502(a).

7.5 A claimant must exhaust this appeal procedure before bringing a civil action, unless the Plan fails to follow it.

8. Funding

8.1 Benefits are paid from the Employer's general assets. No trust is established.

8.2 No employee contributions are required or accepted. The Plan is funded entirely by the Employer.

8.3 The Employer is solely responsible for funding every claim payable under the Plan. Nothing in this document obliges the Administrator to advance its own funds to pay a claim.

8.4 No Covered Person has any right, title, or interest in the Employer's assets by reason of the Plan, and nothing in the Plan creates a trust or fiduciary relationship between the Employer and any Covered Person other than as ERISA requires.

9. Administration

9.1 Named Fiduciary and Plan Administrator. The Employer, as required by ERISA §402(a). The Employer has discretionary authority to interpret the Plan, determine eligibility, and decide appeals, and its determinations are final and binding subject to ERISA.

9.2 The Administrator. The Employer has engaged Denta, Inc. to perform administrative and ministerial functions, including eligibility maintenance, claim intake, applying the terms of this document to submitted claims, payment, and reporting. The Administrator has no discretionary authority over the Plan, its assets, or the final disposition of any claim, and is not a fiduciary within the meaning of ERISA §3(21).

9.3 Agent for service of legal process. The Employer, at its principal place of business.

9.4 Records. The Plan's records are kept on a Plan Year basis.

10. COBRA

10.1 Where the Employer employed 20 or more employees on more than 50% of its typical business days in the preceding calendar year, a Covered Person who loses coverage because of a qualifying event may elect to continue coverage under COBRA.

10.2 Qualifying events are the Participant's termination of employment for reasons other than gross misconduct, a reduction in the Participant's hours, the Participant's death, divorce or legal separation, and a Dependent child ceasing to be a Dependent.

10.3 Continuation runs for 18 months from the qualifying event, or 36 months for a qualifying event other than termination or reduction of hours.

10.4 A person electing continuation pays 102% of the applicable premium, determined by the Employer on a reasonable actuarial basis or by reference to the cost of coverage in the preceding determination period.

10.5 Where the Employer employed fewer than 20 employees, this Section does not apply.

11. HIPAA privacy

This Section is the plan document amendment required by 45 CFR §164.504(f)(2). The Plan Sponsor certifies to it separately.

11.1 The Plan may disclose protected health information ("PHI") to the Plan Sponsor only after the Plan Sponsor has certified that these provisions have been adopted and that it agrees to them.

11.2 The Plan Sponsor will not use or further disclose PHI other than as permitted by these provisions or as required by law.

11.3 The Plan Sponsor will ensure that any agent to whom it provides PHI agrees to the same restrictions.

11.4 The Plan Sponsor will not use or disclose PHI for employment-related actions or decisions, or in connection with any other benefit plan of the Plan Sponsor.

11.5 The Plan Sponsor will report to the Plan any use or disclosure inconsistent with these provisions of which it becomes aware.

11.6 The Plan Sponsor will make PHI available for access under 45 CFR §164.524, for amendment under §164.526, and for an accounting of disclosures under §164.528.

11.7 The Plan Sponsor will make its internal practices, books, and records relating to PHI received from the Plan available to the Secretary of Health and Human Services.

11.8 The Plan Sponsor will, if feasible, return or destroy all PHI received from the Plan when it is no longer needed, and retain no copies. Where that is not feasible, it will limit further uses and disclosures to the purposes that make return or destruction infeasible.

11.9 Adequate separation. Only employees of the Plan Sponsor whom the Plan Sponsor has designated as responsible for benefits administration may access PHI received from the Plan, they may use it only to perform plan administration functions, and the Plan Sponsor will apply its ordinary disciplinary process to any failure to comply.

11.10 Nothing in this Section restricts disclosure of summary health information for the purposes permitted by 45 CFR §164.504(f)(1)(ii), or of whether an individual is enrolled in the Plan.

12. Amendment and termination

12.1 The Employer may amend or terminate the Plan at any time, by written action.

12.2 Termination does not affect the Employer's obligation to pay a claim for a Covered Service furnished before the termination date and filed within the deadline in Section 6.2.

12.3 No amendment may divert Plan assets to a purpose other than paying benefits and reasonable administrative expenses.

13. General

13.1 Not a contract of employment. Nothing in the Plan gives any person a right to continued employment.

13.2 Non-alienation. Benefits are not assignable and are not subject to attachment, garnishment, or the claims of creditors, except that the Plan may pay a dentist directly for a Covered Service.

13.3 Recovery of overpayment. Where the Plan pays more than it owes, it may recover the excess from the person or entity that received it, including by offsetting future payments.

13.4 Fraud. A Covered Person who knowingly submits a false or fraudulent claim may have coverage terminated and is liable to the Plan for any amount paid on that claim.

13.5 Governing law. ERISA governs, and state law applies only to the extent ERISA does not preempt it.

13.6 Severability. If a provision is held unenforceable, the rest stays in effect.