Distributed to every covered employee within 90 days of coverage starting, as ERISA §102 requires. Plain language on purpose: the regulation requires it be understandable by the average participant.

Your dental and vision benefit

Summary Plan Description

{{COMPANY_LEGAL_NAME}} pays for your dental and vision care, up to {{ANNUAL_MAXIMUM}} a year, through a health reimbursement arrangement. This summary explains how it works.

What you get

Each covered person has {{ANNUAL_MAXIMUM}} a year to spend on dental and vision care. If your dependents are covered too, each of them has that amount separately. Because your employer pays, the money is not taxed as income to you.

The plan pays for:

• Check-ups, cleanings, and X-rays
• Fillings, crowns, root canals, and gum treatment
• Dentures, bridges, implants, and oral surgery
• Braces and other orthodontics
• Eye exams, prescription glasses, and contact lenses

It does not pay for teeth whitening, veneers or contouring done purely for appearance, non-prescription eyewear, anything above your annual amount, or care you receive before your coverage starts or after it ends.

Who is covered

Every employee of {{COMPANY_LEGAL_NAME}} is eligible from their first day of work. There is no minimum number of hours and no waiting period. Owners who are taxed as self-employed cannot take part, because the tax code does not allow it.

If your employer covers dependents, that means your spouse or domestic partner and your children under 27, including stepchildren, adopted children, and children you are the legal guardian of.

You can opt out at any time by telling your employer, and opt back in at the start of a later year.

Which dentist or eye doctor you can see

Any licensed dentist, optometrist, or ophthalmologist. There is no network and no list to check. Your benefit is the same wherever you go. Where Denta has agreed a rate with a provider, their prices are lower, so your annual amount stretches further.

When coverage ends

Coverage ends on the last day of the month in which you leave. Care you had while covered can still be claimed for 12 months after the appointment.

Your amount resets on 1 January

Every 1 January you get a fresh {{ANNUAL_MAXIMUM}}. Anything you did not use does not carry over. If the plan started partway through a year, you still get the full amount for the rest of that year.

How to use it

Most of the time, your provider bills Denta directly and you pay nothing at the desk beyond anything above your annual amount. If you pay for something yourself, send the itemized receipt to Denta and you will be paid back. Either way, the claim has to reach Denta within 12 months of the date of service.

If a claim is turned down

Denta will write to you explaining why, which part of the plan applies, what else it would need, and how to appeal.

You have 180 days to appeal. Send your appeal to {{COMPANY_LEGAL_NAME}}, which decides appeals as the plan administrator. You can include anything you want considered and ask for free copies of everything relevant to your claim. Someone not involved in the first decision reviews it fresh. You will get an answer within 60 days. If your appeal is turned down, you have the right to bring a civil action under section 502(a) of ERISA.

Who pays for this

Your employer, entirely, out of its own money. Nothing is taken out of your paycheck. The plan is a self-funded health reimbursement arrangement, which means your employer pays each claim as it comes rather than buying an insurance policy.

If you leave

If your employer had 20 or more employees last year, you can usually keep this coverage for up to 18 months after you leave by paying for it yourself, under a federal law called COBRA. You will get a separate notice explaining it when it applies. Employers with fewer than 20 employees are not covered by COBRA, so coverage simply ends.

Your privacy

Health information about you is protected by HIPAA. A separate Notice of Privacy Practices explains how the plan uses it and what rights you have. Your employer may only see your individual health information in narrow circumstances, and never to make employment decisions.

Plan facts

Plan name	The {{COMPANY_LEGAL_NAME}} Dental and Vision Health Reimbursement Arrangement
Plan sponsor	{{COMPANY_LEGAL_NAME}}
State of formation	{{COMPANY_STATE}}
Employer ID number	{{COMPANY_EIN}}
Plan number	501
Type of plan	Welfare benefit plan: a health reimbursement arrangement providing limited-scope dental and vision benefits
Type of administration	Self-funded, administered by Denta, Inc. under an Administrative Services Agreement
Plan administrator	{{COMPANY_LEGAL_NAME}}
Agent for service of legal process	{{COMPANY_LEGAL_NAME}}, at its principal place of business
Plan year	1 January to 31 December
Funding	Employer general assets

Your rights under ERISA

As a participant in this plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974.

You may examine, without charge, at the plan administrator's office, all documents governing the plan.

You may obtain copies of those documents on written request to the plan administrator, who may charge a reasonable fee.

In addition to creating rights for participants, ERISA imposes duties on the people responsible for operating the plan. The people who operate your plan, called fiduciaries, have a duty to do so prudently and in the interest of you and other participants. No one may fire you or discriminate against you to prevent you from obtaining a benefit or exercising your ERISA rights.

If your claim is denied or ignored, in whole or in part, you have a right to know why, to obtain copies of documents relating to the decision without charge, and to appeal, within certain time schedules.

Under ERISA there are steps you can take to enforce these rights. If you request materials from the plan and do not receive them within 30 days, you may file suit in federal court, and the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive them, unless they were not sent for reasons beyond the administrator's control. If you have a claim which is denied or ignored, in whole or in part, you may file suit in a state or federal court. If plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees.

If you have questions about your plan, contact the plan administrator. If you have questions about this statement or about your rights under ERISA, contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.