Employee Benefits Home | Forms | Contact Mitchell County Schools, NC | Plan Year: September 1, 2007 to August 31, 2008

Dental Plan     Dental Plan Details   Rates         Ameritas Dental Contact                                           Please call your Personnel Office for all questions concerning this plan.

Flexible Spending Accounts | Cancer Plan | Dental Plan Vision Plan | Disability Plan | Whole Life Plan

Effective Date: September 1, 2008

COMBINED CALENDAR YEAR DEDUCTIBLE
$50.00 per individual for Type 2 (Basic) and Tye 3 (Major) Procedures (3 times famiy limit). After the date that 3 members of a family have each satisfied their individual deductible, the entire deductile or any remaining portion of the deductible for any family member will be waived for the rest of that calendar year.

Type 1 - PREVENTIVE AND DIAGNOSTIC
Type 1 benefts are payable at 100% U&C**. No deductible applies.

Type 2 - BASIC PROCEDURES
Type 2 benefits are payable at 80% U&C**. $50.00 deductible applies

Type 3 - MAJOR PROCEDURES
Type 3 Benefits are payable at 50% U&C**. $50.00 deductible applies

ORTHODONTIA - ADULT AND CHILD(REN)
Paid at 50% U&C** with a $1,000 lifetime maximum. No deductible applies.

Late Entrant: There is a 12 month waiting period on all services except for cleanings, exams and fluoride applications for employees who do not enroll when first eligible for coverage. The waiting period will be waived for employees who eroll when first eligible.

ANNUAL MAXIMUM BENEFIT

• Type 1, Type 2, and Type 3 Procedures - $1,000* per calendar year per person
• Orthodontia Procedures - $1,000 Lifetime per person (carryover doesn't apply)

This plan includes a maximum carryover for dental. Each Insured (employee and/or dependent) will qualify for a dental maximum carryover if they:
1. Visit a dentist between January 1 and December 31 of each year.
2. Submit a claim for a covered procedure prior to March 1 following year.
3. Total dental benefits paid for the calendar year must be less than $500.

If you meet all 3 requirements then you will be eligible for the Annual Maximum Carryover benefit. This benefit will provide you with an additional $250 toward your annual dental maximumfor the following year. In future years, if you continue to meet these requirements, you will continue to see an increase in you annual maximum by $250 until you have reached an annual maximum carryover limit of $1,000. This benefit allows you to accumulate up to a $2,000 annual dental maximum.

Eligible Employees
You are eligible for insurance if you are a full-time active employee working at least 30 hours per week.

Eligible Dependents
Provides Coverage On:
- Your Spouse
- Children up to at 19 and unmarried (up to 24 if wholly dependent upon you for maintenance and support and if enrolled as a full-time student in an accredited school or college)

Predetermination of Benefits
A treatment plan MAY be filed if a proposed course of treatment will exceed $200.00. With this information, Ameritas can determine the benefits payable under this policy prior to the work actually being done. If will give the insured the amount payable, along with an idea of the out of pocket expense.

Coordination of Benefits
If you or any of your dependents incur charges which are covered be any other group plan, the benefits of this plan will be coordinated with the benefits of the other plan so that the total benefits received are not greater than the changes incurred.

Certificate of Insurance
The Certificate of Insurance issued to you describes in detail th benefits and limitations of this plan. This brochure is for general information only.

Section 125
This policy is provided as part of the Policyholder's Section 125 Plan. Each member has the option under the Section 125 Plan of participating or not participating in this policy.

A member may change their election only during an annual election period, except for a change in family status. Examples of such events would be marriage, divorce, birth of a child, death of a spouse or child or termination of employment. Please see your plan administrator for details.

Orthodontia Limitations (This not a complete list)
No benefit is payable for expenses incurred:
- In connection with a Treatment Program which was begun before the individual became insured for orthodontic benefits
- During any quarter of a Treatment Program if the individual was not continuously insured for orthodontic benefits for the entire quarter
- After the individual's insurance for orthodontic benefits terminates

Limitations and Exclusions (This is not a complete list)
- For any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the 2nd bicuspid are considered cosmetic
- Charges incurred prior to the date the individual became insured under this plan, or following the date of termination of coverage
- Services which are not recommended by a dentist or which are not required for necessary treatment
- Expenses incurred to replace lost or stolen appliances
- Expenses incurred by an insured because of a sickness for which he/she is eligible for benefits under Worker's Compensation Act or similar laws

This insurance is underwritten by Ameritas Life Insurance Corporation.

For Claims/Customer Service Questions Call Ameritas At: (800) 487-5553

Monthly Dental Rates