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Texas Marketplace Dental Policy Terms

EMI Health is pleased to offer dental plans in Texas’s Federal Health Insurance Marketplace for Individuals. The information below outlines some important aspects of the EMI Health plans. Enrollees will receive a formal policy and are encouraged to read it in its entirety.

Out-of-network liability and balance billing

The Plan uses a contracted provider network. An In-network Provider is a Provider who has an agreement in effect with EMI Health to accept a reduced rate for services rendered to Insureds. This is known as the negotiated rate or Maximum Allowable Charge. The In-network Provider cannot bill the Insured for any amount in excess of the Maximum Allowable Charge. The Insured may obtain a copy of the directory of Participating Providers at www.emihealth.com or by calling 801-262-7475.

Although benefits under the Plan are generally greater for services provided by In-network Providers, the choice to use an In-network Provider or Out-of-network Provider is entirely up to the Insured. EMI Health does not employ In-network Providers, and they are not agents or partners of EMI Health. Providers participate in the network only as independent contractors. In-network Provider status is not an endorsement or representation by the Policyholder or EMI Health as to the qualifications (or quality of care) of any particular Provider.

When dental services are received from an Out-of-network Provider, EMI Health calculates its share of the Maximum Allowable Charge for the service using the applicable percentage from the Schedule of Benefits for the Plan the Insured selected and sends it directly to the Insured if benefits are not assigned to the dentist. If the Insured has assigned right to payment to the Dentist, EMI Health’s obligation is discharged upon its payment made directly to the Dentist.

The Insured is responsible for payment of the Out-of-Network Provider’s total fee. Out-of-Network Providers will bill the Insured for their normal charges, which may be higher than the Maximum Allowable Charge for the service. The Insured may be required to pay the dentist and then submit a claim to EMI Health for reimbursement. Because the EMI Health payment for services may be less than the Out-of-Network Dentist’s actual charges, the Insured’s out-of-pocket cost may be significantly higher. In no event will EMI Health reimburse an Out-of-Network Dentist in an amount greater than the actual billed charge.

In the unlikely event that there is no Out-of-Network Provider available within the Insured’s county to perform the services needed, Insureds may contact EMI Health’s customer services department at 801-262-7475 for assistance finding an In-network Provider near them.

Enrollee claims submission

EMI Health must receive written notice before the 21st day after the date of the occurrence or beginning of any loss covered by the policy, or as soon as reasonably possible. Except as otherwise provided in the policy or by Texas law, no benefits provided under the policy shall be paid to, or on behalf of, an Insured unless the Insured, or his authorized representative, has first submitted a written or Electronic Data Interchange (EDI) claim for benefits to EMI Health. Claims may be submitted at any time within 12 months of the date the expenses are incurred. If, however, the Insured shows that it was not reasonably possible to submit the claim within that time period, then a claim may be submitted as soon as reasonably possible.

EMI Health will provide the Insured or the Provider with a claim form within 15 days after receiving a notice of a claim. A dental claim form may also be downloaded from www.emihealth.com under Member Forms. To make a claim, the form should be completed and signed by the Provider who performed the services and by the patient (or the parent or guardian if the patient is a minor) and submitted to the address below. If EMI Health does not send the Insured or the Provider a claim form within 15 days after notice regarding a claim, the requirements for the proof of loss outlined in the Proof of Loss section will be deemed to have been complied with, as long as the Insured provides written proof that explains the type and extent of the loss that he or she is making a claim for within the time established for filing proof of loss.

PO Box 21482
Eagan, MN 55121

If the claim form is not properly completed, it cannot be processed, and it will be returned. For additional information, contact EMI Health’s customer service department at 801-262-7475 or toll free at 800-662-5851.

Grace periods and claims pending policies during the grace period

A Grace Period is the period that shall be granted for the payment of any policy charge, during which time the policy shall continue in force. In no event shall the Grace Period extend beyond the date the policy terminates.

A 31-day Grace Period will be granted for payment of premiums accrued after the first premium has been paid. EMI Health may discontinue coverage under the policy at the end of the 31-day Grace Period or 31 days following the date on which EMI Health mailed written notice of termination. Partial payment will be treated as nonpayment, unless EMI Health, at its sole discretion, indicates otherwise in writing. During the Grace Period, the policy will remain in force, but the Insured will be liable to EMI Health for premiums accrued during that period.

Upon the payment of a claim under this Policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.

For recipients of advance payments of the premium tax credit, nonpayment of premiums within a 90-day Grace Period following the due date specified above, EMI Health may discontinue coverage under the policy at the end of the 90-day Grace Period following 31 days written notice of termination.

During the Grace Period, the Policy shall continue in force, however, any claims received for services rendered after the first month of the Grace Period, will be held for processing (pended) until Policy charges are paid in full. The Subscriber will remain liable to pay the premium including premium for the Grace Period, and Insureds will continue to be responsible for paying all Copayments, Coinsurance, and Deductibles, as applicable.

Retroactive denials

A retroactive denial is the reversal of a previously paid claim, through which the insured may become responsible for payment. Claims can be denied retroactively for various reasons. The most common is because coverage was retroactively terminated. EMI Health will have the right to recover any payment made in excess of the Plan’s obligations, including retroactive denials. Such recoveries must be initiated within 12 months from the date a payment is made unless the recovery is due to fraud or intentional misrepresentation of material fact by the Insured. This right of recovery applies to payments made to the Insured or to the provider. If such overpayment is made to the Insured, he or she must promptly refund the amount of the excess. If the overpayment is made to a provider, and attempts to recover overpayments from said provider are exhausted, the Insured may be responsible for reimbursement to EMI Health. EMI Health may, at its sole discretion, offset any future benefits against any overpayment. In order to avoid overpayments and retroactive denials, it is important for the Insured to take responsibility in paying premiums on time and reporting to EMI Health any changes in the status of other insurance coverage.

Enrollee recoupment of overpayments

Requests for premium adjustments (whether the result of error, administrative delay, or any other cause) requiring the return of unearned prepaid premiums to the Insured, must be in writing and be received by EMI Health the month prior to the end of coverage. Prepaid premiums for periods extending after coverage ends may be refunded. EMI Health will not refund any premiums paid for periods in which there was coverage. EMI Health may request evidence that an adjustment is necessary. In no case will EMI Health consider a refund for more than the 12-month period prior to the request. Requests for refunds of premium should be sent to the following address:

5101 S Commerce Drive
Murray, Utah 84107

Medical necessity and prior authorization timeframes and enrollee responsibilities

EMI Health dental plans do not require prior authorization of services; however, before starting a dental treatment for which the charge is expected to be $300 or more, a predetermination of benefits is recommended. To obtain a predetermination, the dentist must itemize all recommended services and costs and attach all supporting documents, including x-rays. EMI Health will notify the dentist of the benefits payable under the Plan. The Insured and the dentist can then decide on the course of treatment, knowing in advance how much the Plan will pay. The Plan does not cover cosmetic treatment or services that are not medically necessary.

Information on Explanations of Benefits (EOBs)

EMI Health will send an EOB to the Insured following the receipt and adjudication of a claim. An EOB is a statement explaining the treatments for which the Plan paid on behalf of the Insured, the amount of the Plan’s payment, and the Insured’s financial responsibility pursuant to the terms of the policy. For information on how to read your EOB, click here.

Coordination of benefits (COB)

The Coordination of Benefits (COB) provision applies when a person has 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 accord 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 equal 100 percent of the total allowable expense.