Blue Cross Blue Shield Basic Certificates and Rider

COMPREHENSIVE BENEFITS AND CLAIMS ADMINISTRATION

August 8, 2005

HFCC-FT, AFT 1650

DENTAL BENEFITS

This benefit applies when covered dental charges are incurred by a person while covered under this Plan.

BENEFIT PAYMENT

Each Calendar Year benefits will be paid to or on behalf of a Covered Person for eligible dental charges in excess of the deductible amount. Payment will be made at the rate shown under Dental Percentage Payable in the Schedule of Benefits. No benefits will be paid in excess of the Maximum Benefit Amount.

MAXIMUM BENEFIT AMOUNT

The Maximum dental benefit amount is shown in the Schedule of Benefits.

DENTAL CHARGES

Dental charges are the Usual and Reasonable Charges made by a Dentist or other Physician for necessary care, appliances or other dental material listed as a covered dental service.

A dental charge is considered incurred at the time a) an impression is made for an appliance or modification of an appliance, b) the tooth or teeth are prepared for a crown, bridge or gold restoration, c) the pulp chamber is opened for root canal therapy, or d) any other dental service or supply is received by a covered person. However, there are times when one overall charge is made for all or part of a course of treatment (i.e. for orthodontics). In this case, the Claims Administrator will apportion that overall charge to each of the separate visits or treatments. The pro rata charge will be considered to be incurred as each visit or treatment is completed.

Class A Services:
Preventive and Diagnostic Dental Procedures

The limits on Class A services are for routine services. If dental need is present, this Plan will consider for reimbursement services performed more frequently than the limits shown.

(1) Routine oral exams. This includes the cleaning and scaling of teeth. Limit of 2 per Covered Person each 12 month period.

(2) One bitewing x-ray series every 12 months.

(3) One full mouth x-ray every five years.

(4) Fluoride treatment.

(5) Space maintainers.

(6) Emergency palliative treatment for pain.

(7) Dental x-rays not listed above.

(8) Sealants for Dependent children age 12 and under.

(9) Medically Necessary tests.

Class B Services:
Basic Dental Procedures

(1) Fillings, including gold restorations (if necessary).

(2) Oral surgery.

(3) Periodontics (gum treatments).

(4) Endodontics (root canals).

(5) Extractions.

(6) General anesthetics, upon demonstration of Medical Necessity.

(7) Crowns, inlays and onlays.

(8) Repair of crowns, bridgework and removable dentures.

Class C Services:
Major Dental Procedures

(1) Bridges.

(2) Partial, full or removable dentures. This service also includes all adjustments made during 6 months following the installation.

(3) Rebasing or relining of removable dentures.

(4) Recementing bridges, crowns or inlays.

Class D Services:
Orthodontic Treatment and Appliances

This is treatment to move teeth by means of appliances to correct a handicapping malocclusion of the mouth. Also, minor treatment to control harmful habits and tooth guidance will be covered under this benefit.

These services include preliminary study, x-rays, diagnostic casts and treatment plan, active treatments and retention appliance.

Payments for comprehensive full-banded orthodontic treatments are made in installments.

PREDETERMINATION OF BENEFITS (Optional)

Before starting a dental treatment for which the charge is expected to be $200 or more, a predetermination of benefits form may be submitted.

The Dentist must itemize all recommended services and costs and attach all supporting x-rays to the form.

The Dentist should send the form to the Claims Administrator at this address:

CBCA
PO Box 902
Beattyville, KY 41311

The Claims Administrator will notify the Dentist of the benefits payable under the Plan. The Covered Person and the Dentist can then decide on the course of treatment, knowing in advance how much the Plan will pay.

If a description of the procedures to be performed, x?rays and an estimate of the Dentist's fees are not submitted in advance, the Plan reserves the right to make a determination of benefits payable taking into account alternative procedures, services or courses of treatment, based on accepted standards of dental practice. If verification of necessity of dental services cannot reasonably be made, the benefits may be for a lesser amount than would otherwise have been payable.

ALTERNATE TREATMENT

Many dental conditions can be treated in more than one way. This Plan has an "alternate treatment" clause which governs the amount of benefits the Plan will pay for treatments covered under the Plan. If a patient chooses a more expensive treatment than is needed to correct a dental problem according to accepted standards of dental practice, the benefit payment will be based on the cost of the treatment which provides professionally satisfactory results at the most cost?effective level.

For example, if a regular amalgam filling is sufficient to restore a tooth to health, and the patient and the Dentist decide to use a gold filling, the Plan will base its reimbursement on the Usual and Reasonable Charge for an amalgam filling. The patient will pay the difference in cost.

Third Party Administrator:

CBCA, Inc.
P.O. Box 902
Beattyville, KY 41311

Phone: (800) 832-3709
FAX: (952) 946-7547

EMPLOYEES CAN CALL CBCA AT 800-832-3709
To verify eligibility and benefits call:
CBCA at 800-832-3709
BILLING INSTRUCTIONS

NO CLAIM FORMS ARE REQUIRED, however, in order for bills to be processed without delay, the following information must be provided on the statement.

1. Name of Employer
-Henry Ford Community College 6. Provider's Name & Tax
      I.D.

2. Group Number
-100750 7. Date of Service

3. Name of Employee
8. Description and Diagnosis

4. Name of Patient 9. If accidental injury, describe
      how, when and where the
      accident happened.

5. Employee Number
-Social Security Number 10. Other coverage information

SEND CLAIMS TO:

CBCA Administrators
PO Box 902
Beattyville, KY 41311

FAX Number: 952-946-7547
E-Mail: GR-customer service@cisgi.com
Website: CBCA Quick Login

August 8, 2005 HFCC-FT, AFT 1650 DENTAL BENEFITS This benefit applies when covered dental charges are incurred by a person while covered under this Plan. BENEFIT PAYMENT Each Calendar Year benefits will be paid to or on behalf of a Covered Person for eligible dental charges in excess of the deductible amount. Payment will be made at the rate shown under Dental Percentage Payable in the Schedule of Benefits. No benefits will be paid in excess of the Maximum Benefit Amount. MAXIMUM BENEFIT AMOUNT The Maximum dental benefit amount is shown in the Schedule of Benefits. DENTAL CHARGES Dental charges are the Usual and Reasonable Charges made by a Dentist or other Physician for necessary care, appliances or other dental material listed as a covered dental service. A dental charge is considered incurred at the time a) an impression is made for an appliance or modification of an appliance, b) the tooth or teeth are prepared for a crown, bridge or gold restoration, c) the pulp chamber is opened for root canal therapy, or d) any other dental service or supply is received by a covered person. However, there are times when one overall charge is made for all or part of a course of treatment (i.e. for orthodontics). In this case, the Claims Administrator will apportion that overall charge to each of the separate visits or treatments. The pro rata charge will be considered to be incurred as each visit or treatment is completed. Class A Services: Preventive and Diagnostic Dental Procedures The limits on Class A services are for routine services. If dental need is present, this Plan will consider for reimbursement services performed more frequently than the limits shown. (1) Routine oral exams. This includes the cleaning and scaling of teeth. Limit of 2 per Covered Person each 12 month period. (2) One bitewing x-ray series every 12 months. (3) One full mouth x-ray every five years. (4) Fluoride treatment. (5) Space maintainers. (6) Emergency palliative treatment for pain. (7) Dental x-rays not listed above. (8) Sealants for Dependent children age 12 and under. (9) Medically Necessary tests. Class B Services: Basic Dental Procedures (1) Fillings, including gold restorations (if necessary). (2) Oral surgery. (3) Periodontics (gum treatments). (4) Endodontics (root canals). (5) Extractions. (6) General anesthetics, upon demonstration of Medical Necessity. (7) Crowns, inlays and onlays. (8) Repair of crowns, bridgework and removable dentures. Class C Services: Major Dental Procedures (1) Bridges. (2) Partial, full or removable dentures. This service also includes all adjustments made during 6 months following the installation. (3) Rebasing or relining of removable dentures. (4) Recementing bridges, crowns or inlays. Class D Services: Orthodontic Treatment and Appliances This is treatment to move teeth by means of appliances to correct a handicapping malocclusion of the mouth. Also, minor treatment to control harmful habits and tooth guidance will be covered under this benefit. These services include preliminary study, x-rays, diagnostic casts and treatment plan, active treatments and retention appliance. Payments for comprehensive full-banded orthodontic treatments are made in installments. PREDETERMINATION OF BENEFITS (Optional) Before starting a dental treatment for which the charge is expected to be $200 or more, a predetermination of benefits form may be submitted. The Dentist must itemize all recommended services and costs and attach all supporting x-rays to the form. The Dentist should send the form to the Claims Administrator at this address: CBCA PO Box 902 Beattyville, KY 41311 The Claims Administrator will notify the Dentist of the benefits payable under the Plan. The Covered Person and the Dentist can then decide on the course of treatment, knowing in advance how much the Plan will pay. If a description of the procedures to be performed, x?rays and an estimate of the Dentist's fees are not submitted in advance, the Plan reserves the right to make a determination of benefits payable taking into account alternative procedures, services or courses of treatment, based on accepted standards of dental practice. If verification of necessity of dental services cannot reasonably be made, the benefits may be for a lesser amount than would otherwise have been payable. ALTERNATE TREATMENT Many dental conditions can be treated in more than one way. This Plan has an "alternate treatment" clause which governs the amount of benefits the Plan will pay for treatments covered under the Plan. If a patient chooses a more expensive treatment than is needed to correct a dental problem according to accepted standards of dental practice, the benefit payment will be based on the cost of the treatment which provides professionally satisfactory results at the most cost?effective level. For example, if a regular amalgam filling is sufficient to restore a tooth to health, and the patient and the Dentist decide to use a gold filling, the Plan will base its reimbursement on the Usual and Reasonable Charge for an amalgam filling. The patient will pay the difference in cost. Third Party Administrator: CBCA, Inc. P.O. Box 902 Beattyville, KY 41311 Phone: (800) 832-3709 FAX: (952) 946-7547 EMPLOYEES CAN CALL CBCA AT 800-832-3709 To verify eligibility and benefits call: CBCA at 800-832-3709 BILLING INSTRUCTIONS
NO CLAIM FORMS ARE REQUIRED, however, in order for bills to be processed without delay, the following information must be provided on the statement.
1. Name of Employer -Henry Ford Community College	6. Provider's Name & Tax I.D.
2. Group Number -100750	7. Date of Service
3. Name of Employee	8. Description and Diagnosis
4. Name of Patient	9. If accidental injury, describe how, when and where the accident happened.
5. Employee Number -Social Security Number	10. Other coverage information
SEND CLAIMS TO: CBCA Administrators PO Box 902 Beattyville, KY 41311 FAX Number: 952-946-7547 E-Mail: GR-customer service@cisgi.com Website: CBCA Quick Login