2017 Dental Choice & Dental Choice Plus Brochure · 2017 Dental Choice & Dental Choice Plus ... Affordable Care Act requirements One mission: you Meridian ... Statement of Understanding

Form No. 3-189 (09-16)

2017 Dental Choice &

Dental Choice Plus Individual Dental plans that meet Affordable Care Act requirements

One mission: you

Meridian3000 E. Pine Ave.

Meridian, ID 83642

Lewiston866-841-2583208-746-0531

Pocatello275 S. 5th Ave.

Pocatello, ID 83201208-232-6206

Twin Falls1503 Blue Lakes Blvd. N.

Twin Falls, ID 83301208-733-7258

Idaho Falls1910 Channing Way

Idaho Falls, ID 83404208-522-8813

Coeur d’Alene1450 NW Blvd., Suite 106 Coeur d’Alene, ID 83814

208-666-1495

Blue Cross of IdahoSales 888-462-7677

Customer Service 800-365-2345Claims Inquiries 208-331-7347

800-627-1188

bcidaho.com

One mission: you

© 2016 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association

Parent o

r Gu

ardian

Co

nsen

t to A

pp

lication

By co

mp

leting

this sectio

n an

d sig

nin

g th

is app

lication

, I represen

t that th

e perso

n listed

as the ap

plican

t on

this ap

plicatio

n is u

nd

er 18 years of ag

e an

d is m

aking

app

lication

for h

ealth coverag

e with

my fu

ll kno

wled

ge an

d co

nsen

t. I hereb

y accept fu

ll respo

nsib

ility for th

e paym

ent o

f prem

ium

s an

d th

e answ

ers and

info

rmatio

n p

rovided

in th

is app

lication

.

Print N

ame _______________________________________________________________________________________D

ate (mm

/dd/yyyy) __________________A

dd

ress (if different than dependent) _________________________________________________________________

Statem

ent o

f Un

derstan

din

gB

y sign

ing

this ap

plicatio

n, I rep

resent th

at all my an

swers are co

mp

lete an

d accu

rate to th

e best o

f my kn

ow

ledg

e and

belief an

d th

at I u

nd

erstand

and

agree to

the fo

llow

ing

con

ditio

ns:

•N

o independent producer, agent or employee of the insurance carrier can change

any part of this application or waive the requirem

ent that I answer all questions

completely and accurately.

•T he insurance carrier m

ay terminate or rescind an insured’s coverage for any

intentional misrepresentation, om

ission of fact by, concerning or on behalf of anyinsured that w

as or would have been m

aterial to the insurance carrier’s acceptance ofa risk, extension of coverage, provision of benefits, or paym

ent of any claim.

•If this application is appro ved, coverage for m

e and any eligible persons named on this

application will begin on the effective date assigned by the insurance carrier.

•I understand that this application w

ill become part of the contract betw

een theinsurance carrier and m

e.•

I affirm that I have review

ed all answers given on this application and, regardless of

whether an independent producer or other person has filled out the answ

ers for me, I

verify that the answers are true and com

plete.I ackn

ow

ledg

e and

un

derstan

d m

y health

plan

may req

uest o

r disclo

se h

ealth in

form

ation

abo

ut m

e or m

y dep

end

ents (p

erson

s wh

o are elig

ible

for b

enefits coverag

e and

are listed o

n th

e app

lication

) for th

e pu

rpo

se of

facilitating

health

care treatmen

t, paym

ent o

r for th

e pu

rpo

se of b

usin

ess o

peratio

ns n

ecessary to ad

min

ister health

care ben

efits; or as req

uired

by

law.

Health

info

rmatio

n req

uested

or d

isclosed

may b

e related to

treatmen

t or

services perfo

rmed

by:

•A

physician, dentist, pharmacist or other physical or behavioral healthcare practitioner;

•A

clinic, hospital, long-term care or other m

edical facility;•

Any other institution providing care, treatm

ent, consultation, pharmaceuticals or

supplies or;•

An insurance carrier or group health plan.

Health

info

rmatio

n req

uested

or d

isclosed

may in

clud

e, bu

t is no

t limited

to: claim

s record

s, corresp

on

den

ce, med

ical record

s, billin

g statem

ents,

diag

no

stic imag

ing

repo

rts, labo

ratory rep

orts, d

ental reco

rds, o

r ho

spital

record

s (inclu

din

g n

ursin

g reco

rds an

d p

rog

ress no

tes).

I affirm th

e answ

ers in th

is “Den

tal Ch

oice/D

ental C

ho

ice Plu

s Ind

ividu

al E

nro

llmen

t Ap

plicatio

n” are com

plete an

d co

rrect. I am p

rovidin

g

these an

swers as p

art of th

e app

lication

pro

cedu

re requ

ired by th

is in

suran

ce carrier to en

roll in

its insu

rance coverage. I u

nd

erstand

th

at the in

suran

ce carrier will rely o

n each

answ

er in m

aking

its d

etermin

ation

to exten

d coverage an

d to

determ

ine th

e type o

f coverage o

ffered. I u

nd

erstand

if I have m

ade any m

isstatemen

t or

om

ission

in th

is app

lication

, the in

suran

ce carrier may take any actio

n

available by law

, inclu

din

g b

ut n

ot lim

ited to, retro

active adju

stmen

t of

prem

ium

s or claim

s. Furth

er, I un

derstan

d th

at any fraud

or in

tentio

nal

misrep

resentatio

n o

f material fact in

my co

mp

letion

of th

is app

lication

is cau

se for retro

active termin

ation

of coverage by th

e insu

rance carrier

and

/or o

ther actio

n availab

le at law. I w

ill pro

mp

tly info

rm th

e insu

rance

carrier in w

riting

if anythin

g h

app

ens b

efore m

y coverage takes effect th

at makes an

answ

er on

this ap

plicatio

n in

com

plete o

r inco

rrect. Fo

llowin

g receip

t of a fu

lly-executed

app

lication

, coverage will b

e in

force as o

f the effective d

ate determ

ined

by the in

suran

ce carrier un

der

app

licable law

.

_____________________________________________ ________________

Ap

plican

t/Resp

on

sible Party S

ign

ature

Date

_____________________________________________ ________________

Sp

ou

se’s Sig

natu

re (if applying for coverage) D

ate

Ind

epen

den

t Pro

du

cer (Agen

t) Info

rmatio

nA

gent’s N

ame

Blu

e Cro

ss of Id

aho

No.

Sig

natu

re of A

gent

Date (m

m/d

d/yy)

For O

ffice U

se On

lyE

lectron

ic System

ID

Form N

o. 3-189A (09-16)

18-080-01/17 18-081-01/17

Policy Form Numbers: 18-079-01/17

Dental Choice PlansWhatever plan you’re looking for, we’ve got you covered. Good oral health is an important part of overall health.

Our Dental Choicesm and Dental Choice Plussm plans offer low deductibles and out-of-pocket maximums, with no waiting periods for Basic and Major Dental Services for covered members under age 19.

Stop problems before they startPreventive care is a top priority under both the Dental Choice and Dental Choice Plus plans. In fact, both plans pay 100 percent of the maximum allowable charge for all preventive dental care after you make your copayment when you visit an in-network provider.

Preventive services include regular exams, cleanings, X-rays and fluoride treatment.

It’s important to know that pediatric dental insurance is considered one of the 10 essential health benefits according to the ACA. Blue Cross of Idaho Dental Choice and Dental Choice Plus plans include dental benefits for those under age 19 that meet ACA requirements.

IMPACT OF THE AFFORDABLE CARE ACT (ACA)

Den

tal C

ho

ice/

Den

tal C

ho

ice

Plu

sIn

div

idu

al E

nro

llmen

t A

pp

licat

ion

Ap

plic

ant

Info

rmat

ion

You

are

: o

New

Ap

plic

ant

o

Res

po

nsi

ble

Par

ty (

Ap

ply

ing

on

ly f

or

dep

end

ent

cove

rag

e)

You

r N

ame

(firs

t, in

itia

l, la

st)

So

cial

Sec

uri

ty N

um

ber

D

ate

of

Bir

th (

mm

/dd

/yyy

y)

Ag

eo

Mal

eo

Fem

ale

Phy

sica

l Ad

dre

ssC

ity,

Sta

te, Z

ip C

od

eC

ou

nty

Mai

ling

Ad

dre

ss (

stre

et o

r ro

ute

)C

ity,

Sta

te, Z

ip C

od

eC

ou

nty

Bill

ing

Ad

dre

ss (

if d

iffer

ent

fro

m m

ailin

g a

dd

ress

)C

ity,

Sta

te, Z

ip C

od

eC

ou

nty

Idah

o R

esid

ent

o Y

es

o N

oPr

efer

red

Ph

on

e

Alt

ern

ate

Ph

on

eo

I d

on’

t h

ave

a p

ho

ne

Em

ail A

dd

ress

Mar

ital

Sta

tus

o S

ing

leo

Mar

ried

Do

yo

u h

ave

a cu

rren

t Id

aho’

s d

rive

r’s

licen

se o

r Id

aho

iden

tifi

cati

on

car

d?

o Y

es

o N

oId

aho

dri

ver’

s lic

ense

or

iden

tifi

cati

on

car

d n

um

ber

___

____

____

____

____

____

____

____

____

____

_ E

xpir

atio

n d

ate

____

____

____

__ If

yo

u a

re u

nab

le t

o p

rovi

de

an Id

aho

dri

ver’

s lic

ense

or

iden

tifi

cati

on

car

d n

um

ber

, to

est

ablis

h r

esid

ency

yo

u m

ust

pro

vid

e co

pie

s o

f tw

o o

ther

fo

rms

of

do

cum

enta

tio

n t

hat

co

nta

in y

ou

r n

ame

and

res

iden

tial

ad

dre

ss w

ith

th

is c

om

ple

ted

ap

plic

atio

n.

Exa

mp

les

incl

ud

e h

om

e m

ort

gag

e st

atem

ent;

leas

e o

r lo

an a

gre

emen

t; h

om

eow

ner

’s, r

ente

r’s,

or

car

insu

ran

ce p

olic

y; o

r cu

rren

t b

ank

stat

emen

ts

(wit

hin

th

e la

st 6

0 d

ays)

. Th

ese

do

cum

ents

mu

st c

on

tain

th

e ap

plic

ant’s

nam

e an

d r

esid

enti

al a

dd

ress

.

Dep

end

ent

Info

rmat

ion

– L

ist a

ll el

igib

le d

epen

dent

s yo

u w

ish

to e

nrol

l, in

clud

ing

any

child

who

is u

nder

the

age

of 2

6 or

who

is m

edic

ally

cer

tifie

d as

dis

able

d an

d de

pend

ent u

pon

you

for s

uppo

rt (c

opy

of c

ertif

icat

ion

requ

ired)

. If y

ou h

ave

mor

e de

pend

ents

to in

clud

e, m

ake

a co

py o

f thi

s pa

ge a

nd a

ttac

h.

List

all

elig

ible

dep

end

ents

yo

u w

ish

to

en

roll,

incl

ud

ing

any

ch

ild w

ho

is u

nd

er t

he

age

of

26; o

r w

ho

is m

edic

ally

cer

tifi

ed a

s d

isab

led

an

d

dep

end

ent

on

par

ent

for

sup

po

rt

(co

py

of

cert

ific

atio

n r

equ

ired

).

Dep

end

ent

1: L

egal

Nam

e (fi

rst,

mid

dle

init

ial,

last

)R

elat

ion

ship

:

o L

egal

sp

ou

se

o C

hild

o

Ste

p-c

hild

o

Oth

erG

end

er:

o M

ale

o F

emal

e

So

cial

Sec

uri

ty N

um

ber

(re

qu

ired

)D

ate

of

Bir

th (m

m/d

d/yy

)D

oes

dep

end

ent

1 liv

e at

th

e sa

me

add

ress

as

you

? o

Yes

o N

o

Dep

end

ent

2: L

egal

Nam

e (fi

rst,

mid

dle

init

ial,

last

)R

elat

ion

ship

:

o L

egal

sp

ou

se

o C

hild

o

Ste

p-c

hild

o

Oth

erG

end

er:

o M

ale

o F

emal

e

So

cial

Sec

uri

ty N

um

ber

(re

qu

ired

)D

ate

of

Bir

th (m

m/d

d/yy

)D

oes

dep

end

ent

2 liv

e at

th

e sa

me

add

ress

as

you

? o

Yes

o N

o

Dep

end

ent

3: L

egal

Nam

e (fi

rst,

mid

dle

init

ial,

last

)R

elat

ion

ship

:

o L

egal

sp

ou

se

o C

hild

o

Ste

p-c

hild

o

Oth

erG

end

er:

o M

ale

o F

emal

e

So

cial

Sec

uri

ty N

um

ber

(re

qu

ired

)D

ate

of

Bir

th (m

m/d

d/yy

)D

oes

dep

end

ent

3 liv

e at

th

e sa

me

add

ress

as

you

? o

Yes

o N

o

Dep

end

ent

4: L

egal

Nam

e (fi

rst,

mid

dle

init

ial,

last

)R

elat

ion

ship

:

o L

egal

sp

ou

se

o C

hild

o

Ste

p-c

hild

o

Oth

erG

end

er:

o M

ale

o F

emal

e

So

cial

Sec

uri

ty N

um

ber

(re

qu

ired

)D

ate

of

Bir

th (m

m/d

d/yy

)D

oes

dep

end

ent

4 liv

e at

th

e sa

me

add

ress

as

you

? o

Yes

o N

o

Pre

miu

m C

alcu

lati

on

– 1

st m

onth

’s p

rem

ium

requ

ired

with

app

licat

ion.

Tota

l pre

miu

m is

cal

cula

ted

on a

per

-per

son

basi

s. P

rem

ium

s fo

r dep

ende

nts

unde

r age

19

are

capp

ed a

t a 3

-chi

ld ra

te w

ith A

pplic

ant c

over

age.

See

Pre

miu

m C

hart

for a

pplic

able

rate

s.

Req

ues

ted

Eff

ecti

ve d

ate:

___

____

___

/___

____

___

/___

____

___

(Ear

liest

effe

ctiv

e da

te w

ill b

e th

e 1s

t of

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th f

ollo

win

g re

ceip

t of

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licat

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ium

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men

t)

Pla

n S

elec

ted

: o

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ice

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Den

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ium

$

© 2

016

by B

lue

Cro

ss o

f Id

aho,

an

inde

pend

ent

licen

see

of t

he B

lue

Cro

ss a

nd B

lue

Shi

eld

Ass

ocia

tion

3000

E. P

ine

Ave

. • M

erid

ian

, Id

aho

836

42 •

208

-345

-455

0M

ailin

g A

dd

ress

: P.O

. Box

740

8 •

Bo

ise,

ID 8

3707

-140

8

Form

No.

3-1

89A

(09-

16)

Dental Choice PlansWhatever plan you’re looking for, we’ve got you covered. Good oral health is an important part of overall health.

Our Dental Choicesm and Dental Choice Plussm plans offer low deductibles and out-of-pocket maximums, with no waiting periods for Basic and Major Dental Services for covered members under age 19.

Stop problems before they startPreventive care is a top priority under both the Dental Choice and Dental Choice Plus plans. In fact, both plans pay 100 percent of the maximum allowable charge for all preventive dental care after you make your copayment when you visit an in-network provider.

Preventive services include regular exams, cleanings, X-rays and fluoride treatment.

It’s important to know that pediatric dental insurance is considered one of the 10 essential health benefits according to the ACA. Blue Cross of Idaho Dental Choice and Dental Choice Plus plans include dental benefits for those under age 19 that meet ACA requirements.

IMPACT OF THE AFFORDABLE CARE ACT (ACA)

Den

tal C

ho

ice/

Den

tal C

ho

ice

Plu

sIn

div

idu

al E

nro

llmen

t A

pp

licat

ion

Ap

plic

ant

Info

rmat

ion

You

are

: o

New

Ap

plic

ant

o

Res

po

nsi

ble

Par

ty (

Ap

ply

ing

on

ly f

or

dep

end

ent

cove

rag

e)

You

r N

ame

(firs

t, in

itia

l, la

st)

So

cial

Sec

uri

ty N

um

ber

D

ate

of

Bir

th (

mm

/dd

/yyy

y)

Ag

eo

Mal

eo

Fem

ale

Phy

sica

l Ad

dre

ssC

ity,

Sta

te, Z

ip C

od

eC

ou

nty

Mai

ling

Ad

dre

ss (

stre

et o

r ro

ute

)C

ity,

Sta

te, Z

ip C

od

eC

ou

nty

Bill

ing

Ad

dre

ss (

if d

iffer

ent

fro

m m

ailin

g a

dd

ress

)C

ity,

Sta

te, Z

ip C

od

eC

ou

nty

Idah

o R

esid

ent

o Y

es

o N

oPr

efer

red

Ph

on

e

Alt

ern

ate

Ph

on

eo

I d

on’

t h

ave

a p

ho

ne

Em

ail A

dd

ress

Mar

ital

Sta

tus

o S

ing

leo

Mar

ried

Do

yo

u h

ave

a cu

rren

t Id

aho’

s d

rive

r’s

licen

se o

r Id

aho

iden

tifi

cati

on

car

d?

o Y

es

o N

oId

aho

dri

ver’

s lic

ense

or

iden

tifi

cati

on

car

d n

um

ber

___

____

____

____

____

____

____

____

____

____

_ E

xpir

atio

n d

ate

____

____

____

__ If

yo

u a

re u

nab

le t

o p

rovi

de

an Id

aho

dri

ver’

s lic

ense

or

iden

tifi

cati

on

car

d n

um

ber

, to

est

ablis

h r

esid

ency

yo

u m

ust

pro

vid

e co

pie

s o

f tw

o o

ther

fo

rms

of

do

cum

enta

tio

n t

hat

co

nta

in y

ou

r n

ame

and

res

iden

tial

ad

dre

ss w

ith

th

is c

om

ple

ted

ap

plic

atio

n.

Exa

mp

les

incl

ud

e h

om

e m

ort

gag

e st

atem

ent;

leas

e o

r lo

an a

gre

emen

t; h

om

eow

ner

’s, r

ente

r’s,

or

car

insu

ran

ce p

olic

y; o

r cu

rren

t b

ank

stat

emen

ts

(wit

hin

th

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st 6

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89A

(09-

16)

Dental Choice and Dental Choice PlusNo matter if you are at home or on the road, your Blue Cross of Idaho dental plan provides you access to quality dental care. Our network includes 86 percent of Idaho dentists and more than 240,000 dental providers across the United States. Locating a participating provider is easy: just visit bcidaho.com/findaprovider to find a dentist near you.

Dental Choice (Under Age 19)

Dental Choice (Age 19 and Over)

BENEFIT DETAILS IN-NETWORK OUT-OF-NETWORK BENEFIT DETAILS IN-NETWORK OUT-OF-NETWORK

Individual Deductible $0 per member, per benefit period

$100 per member, per benefit period Individual Deductible $50 per member,

per benefit period$100 per member, per benefit period

Annual Out-of-Pocket Maximum

$350 Individual/ $700 Two or more $10,000


None None

Benefit Period Maximum None None Benefit Period Maximum $1,000 $1,000

Preventive Dental Services (No waiting period; Includes

exams, cleanings, X-rays and fluoride)

You pay $55 copayment.

Once you’ve met your deductible,

you pay 50% of the allowed amount.






Basic Dental Services (Includes sealants, fillings,

extractions, periodontal maintenance)






extractions, periodontal maintenance; 6-month waiting

period for members age 19 and over)




you pay 50%. of the allowed amount

Major Dental Services (Root canals, periodontics, crowns, bridges, dentures and dental

implants)






implants; 12-month waiting period for members age 19 and over)





Orthodontia (For non-cosmetic orthodontia in accordance with

Blue Cross of Idaho medical policies; medically-necessary, non-cosmetic treatment; prior

authorization required)






Blue Cross of Idaho medical policies)

No Benefit No Benefit

Dental Choice Plus (Under Age 19)

Dental Choice Plus (Age 19 and Over)








None None






you pay 50% of the allowed amount




Once you’ve met your deductible, you pay 50% of the allowed

amount















implants)


you pay 50%.


you pay 50%.




you pay 50%.


you pay 50%.











Dental Choice (Under Age 19)

Dental Choice (Age 19 and Over)








None None
























you pay 50%. of the allowed amount


implants)





















Dental Choice Plus (Under Age 19)

Dental Choice Plus (Age 19 and Over)








None None










Once you’ve met your deductible, you pay 50% of the allowed

amount















implants)


you pay 50%.


you pay 50%.




you pay 50%.


you pay 50%.











Monthly Premium Rates for 2017 Monthly Premium Rates for 2017

AGEDENTAL CHOICE

DENTAL CHOICE PLUS AGE

DENTAL CHOICE

DENTAL CHOICE PLUS

0-20 $27.68 $33.76 43 $32.75 $38.52

21 $29.21 $34.36 44 $32.75 $38.52

22 $29.21 $34.36 45 $34.82 $40.96

23 $29.21 $34.36 46 $34.82 $40.96

24 $29.21 $34.36 47 $34.82 $40.96

25 $30.38 $35.74 48 $34.82 $40.96

26 $30.38 $35.74 49 $34.82 $40.96

27 $30.38 $35.74 50 $36.79 $43.27

28 $30.38 $35.74 51 $36.79 $43.27

29 $30.38 $35.74 52 $36.79 $43.27

30 $30.41 $35.77 53 $36.79 $43.27

31 $30.41 $35.77 54 $36.79 $43.27

32 $30.41 $35.77 55 $37.59 $44.22

33 $30.41 $35.77 56 $37.59 $44.22

34 $30.41 $35.77 57 $37.59 $44.22

35 $31.15 $36.64 58 $37.59 $44.22

36 $31.15 $36.64 59 $37.59 $44.22

37 $31.15 $36.64 60 $38.50 $45.28

38 $31.15 $36.64 61 $38.50 $45.28

39 $31.15 $36.64 62 $38.50 $45.28

40 $32.75 $38.52 63 $38.50 $45.28

41 $32.75 $38.52 64 $38.50 $45.28

42 $32.75 $38.52 65 and over $39.43 $46.38

Monthly Premium Rates for 2017 Monthly Premium Rates for 2017

AGEDENTAL CHOICE

DENTAL CHOICE PLUS AGE

DENTAL CHOICE

DENTAL CHOICE PLUS

0-20 $27.68 $33.76 43 $32.75 $38.52

21 $29.21 $34.36 44 $32.75 $38.52

22 $29.21 $34.36 45 $34.82 $40.96

23 $29.21 $34.36 46 $34.82 $40.96

24 $29.21 $34.36 47 $34.82 $40.96

25 $30.38 $35.74 48 $34.82 $40.96

26 $30.38 $35.74 49 $34.82 $40.96

27 $30.38 $35.74 50 $36.79 $43.27

28 $30.38 $35.74 51 $36.79 $43.27

29 $30.38 $35.74 52 $36.79 $43.27

30 $30.41 $35.77 53 $36.79 $43.27

31 $30.41 $35.77 54 $36.79 $43.27

32 $30.41 $35.77 55 $37.59 $44.22

33 $30.41 $35.77 56 $37.59 $44.22

34 $30.41 $35.77 57 $37.59 $44.22

35 $31.15 $36.64 58 $37.59 $44.22

36 $31.15 $36.64 59 $37.59 $44.22

37 $31.15 $36.64 60 $38.50 $45.28

38 $31.15 $36.64 61 $38.50 $45.28

39 $31.15 $36.64 62 $38.50 $45.28

40 $32.75 $38.52 63 $38.50 $45.28

41 $32.75 $38.52 64 $38.50 $45.28

42 $32.75 $38.52 65 and over $39.43 $46.38

GENERAL EXCLUSIONS AND LIMITATIONS • Procedures that are not included in the Closed List

of Dental Covered Services; or that are not Medically Necessary for the care of an Insured’s covered dental condition; or that do not have uniform professional endorsement.

• Charges for services that were started prior to the Insured’s Effective Date. The following guidelines will be used to determine the date when a service is deemed to have been started:

• For full dentures or partial dentures: on the date the final impression is taken.

• For fixed bridges, crowns, inlays or onlays: on the date the teeth are first prepared.

• For root canal therapy: on the later of the date the pulp chamber is opened or the date canals are explored to the apex.

• For periodontal Surgery: on the date the Surgery is actually performed.

• For all other services: on the date the service is performed.

• For orthodontic services, if benefits are available under this Policy: on the date any bands or other appliances are first inserted.

• Cast restorations (crowns, inlays or onlays) for teeth that are restorable by other means (i.e., by amalgam or composite fillings).

• Replacement of an existing crown, inlay or onlay that was installed within the preceding five (5) years or replacement of an existing crown, inlay or onlay that can be repaired.

• Appliances, restorations or other services provided or performed solely to change, maintain or restore vertical dimension or occlusion.

• A service for cosmetic purposes, unless necessitated as a result of Accidental Injuries received while the Insured was covered by Blue Cross of Idaho.

• In excess of the Maximum Allowance.• A partial or full removable denture for fixed bridgework, or

the addition of teeth thereto, if involving a replacement or modification of a denture or bridgework that was installed during the preceding five (5) years.

• Orthodontic services and supplies unless otherwise specifically listed in the Closed List of Dental Covered Services.

• Replacement of lost or stolen appliances. • Ridge augmentation procedures.• Any procedure, service or supply other than vestibuloplasty,

alveoloplasty or alveolectomy required to prepare the alveolus, maxilla or mandible for a prosthetic appliance. Excluded services include, but are not limited to stomatoplasty and synthetic bone grafts to the alveolars, maxilla or mandible.

• Any procedure, service or supply required directly or indirectly to treat a muscular, neural, orthopedic or skeletal disorder, dysfunction or Disease of the temporomandibular joint (jaw hinge) and its associated structures including, but not limited to, myofascial pain dysfunction syndrome.

• Orthognathic Surgery, including, but not limited to, osteotomy, ostectomy and other services or supplies to augment or reduce the upper or lower jaw.

• Temporary dental services. Charges for temporary services are considered an integral part of the final dental services and are not separately payable.

• Any service, procedure or supply for which the prognosis for success is not reasonably favorable as determined by Blue Cross of Idaho.

• Myofunctional therapy and biofeedback procedures.• For hospital Inpatient or Outpatient care for extraction of

teeth or other dental procedures.• Occlusal adjustments.• Not prescribed by or upon the direction of a Provider.• Investigational in nature.• Provided for any condition, Disease, Illness or Accidental

Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers’ Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party;

• Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefor would vary, or are or would be affected by the existence of coverage under this Policy; or

• For which payment has been made under Medicare Part A and/or Part B.

• Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared.

• Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured’s household.

• Received from a dental, vision or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group.

• For personal hygiene, comfort, beautification or convenience items even if prescribed by a Dentist, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs.

• For telephone consultations; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses, or for mileage, transportation, food or lodging expenses billed by a Dentist or other Provider.

• For Congenital Anomalies, or for developmental malformations, unless the patient is an Eligible Dependent child.

• For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence.

• For treatment or other health care of any Insured in connection with an Illness, Disease, Accidental Injury or other condition which would otherwise entitle the Insured to Covered Services under this Policy, if and to the extent those benefits are payable to or due the Insured under any medical payments provision, no fault provision, uninsured motorist provision, underinsured motorist provision, or other first party or no fault provision of any automobile, homeowner’s or other similar policy of insurance, contract or underwriting plan.

• In the event Blue Cross of Idaho for any reason makes payment for or otherwise provides benefits excluded by this provision, it shall succeed to the rights of payment or reimbursement of the compensated Provider, the Insured, and the Insured’s heirs and personal representative against all insurers, underwriters, self-insurers or other such obligors contractually liable or obliged to the Insured or his or her estate for such services, supplies, drugs or other charges so provided by Blue Cross of Idaho in connection with such Illness, Disease, Accidental Injury or other condition.

• Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage or for which reimbursement or payment is contemplated under an agreement entered into with a third party.

• Provided to persons who were enrolled as Eligible Dependents after they cease to qualify as Eligible Dependents due to a change in eligibility status which occurs during the Policy term.

• Provided outside the United States, which if had been provided in the United States, would not be Covered Services under this Policy.

• Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury.

• For acupuncture or hypnosis.• Repair, removal, cleansing or reinsertion of Implants.• Precision or semi-precision attachments (including Implants

placed to support a fixed or removable denture).• Denture duplication. • Oral hygiene instruction.• Treatment of jaw fractures.• Charges for acid etching.• Charges for oral cancer screening which are included in a

regular oral examination.• No benefits are available for replacement and/or repair of

orthodontic appliances. This includes removable and/or fixed retainer.

Blue Cross of Idaho does not discriminate on the basis of basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

Dental Choice/Dental Choice PlusIndividual Enrollment Application

Applicant InformationYou are: o New Applicant o Responsible Party (Applying only for dependent coverage)

Your Name (first, initial, last) Social Security Number Date of Birth (mm/dd/yyyy) Age o Male o Female

Physical Address City, State, Zip Code County

Mailing Address (street or route) City, State, Zip Code County

Billing Address (if different from mailing address) City, State, Zip Code County

Idaho Resident o Yes o No

Preferred Phone Alternate Phone o I don’t have a phone Email Address Marital Status o Single o Married

Do you have a current Idaho’s driver’s license or Idaho identification card? o Yes o No

Idaho driver’s license or identification card number ________________________________________ Expiration date ______________

If you are unable to provide an Idaho driver’s license or identification card number, to establish residency you must provide copies of two other forms of documentation that contain your name and residential address with this completed application.

Examples include home mortgage statement; lease or loan agreement; homeowner’s, renter’s, or car insurance policy; or current bank statements (within the last 60 days). These documents must contain the applicant’s name and residential address.

Dependent Information – List all eligible dependents you wish to enroll, including any child who is under the age of 26 or who is medically certified as disabled and dependent upon you for support (copy of certification required). If you have more dependents to include, make a copy of this page and attach.

List all eligible dependents you wish to enroll, including any child who is under the age of 26; or who is medically certified as disabled and dependent on parent for support (copy of certification required).

Dependent 1: Legal Name (first, middle initial, last) Relationship: o Legal spouse o Child o Step-child o Other Gender: o Male o Female

Social Security Number (required) Date of Birth (mm/dd/yy)Does dependent 1 live at the same address as you? o Yes o No







Premium Calculation – 1st month’s premium required with application. Total premium is calculated on a per-person basis. Premiums for dependents under age 19 are capped at a 3-child rate with Applicant coverage. See Premium Chart for applicable rates.

Requested Effective date: __________ /__________ /__________ (Earliest effective date will be the 1st of the month following receipt of application and premium payment)

Plan Selected: o Dental Choice o Dental Choice Plus

NOTE: For enrollees over age 19, both plans have a six-month waiting period for Basic Dental Services and 12-month waiting period for Major Dental Services.

Applicant Premium – based on age; see Premium Chart (write in N/A if you are responsible party only) $

Dependent 1 Premium – based on age; see Premium Chart $




Total monthly premium $


3000 E. Pine Ave. • Meridian, Idaho 83642 • 208-345-4550Mailing Address: P.O. Box 7408 • Boise, ID 83707-1408

Form No. 3-189A (09-16)

Parent or Guardian Consent to ApplicationBy completing this section and signing this application, I represent that the person listed as the applicant on this application is under 18 years of age and is making application for health coverage with my full knowledge and consent. I hereby accept full responsibility for the payment of premiums and the answers and information provided in this application.

Print Name ______________________________________________________________________________________________________Date (mm/dd/yyyy) ________________________

Address (if different than dependent) _______________________________________________________________________________

Statement of UnderstandingBy signing this application, I represent that all my answers are complete and accurate to the best of my knowledge and belief and that I understand and agree to the following conditions:

• No independent producer, agent or employee of the insurance carrier can change any part of this application or waive the requirement that I answer all questions completely and accurately.

• The insurance carrier may terminate or rescind an insured’s coverage for any intentional misrepresentation, omission of fact by, concerning or on behalf of any insured that was or would have been material to the insurance carrier’s acceptance of a risk, extension of coverage, provision of benefits, or payment of any claim.

• If this application is approved, coverage for me and any eligible persons named on this application will begin on the effective date assigned by the insurance carrier.

• I understand that this application will become part of the contract between the insurance carrier and me.

• I affirm that I have reviewed all answers given on this application and, regardless of whether an independent producer or other person has filled out the answers for me, I verify that the answers are true and complete.

I acknowledge and understand my health plan may request or disclose health information about me or my dependents (persons who are eligible for benefits coverage and are listed on the application) for the purpose of facilitating healthcare treatment, payment or for the purpose of business operations necessary to administer healthcare benefits; or as required by law.

Health information requested or disclosed may be related to treatment or services performed by:

• A physician, dentist, pharmacist or other physical or behavioral healthcare practitioner;

• A clinic, hospital, long-term care or other medical facility;

• Any other institution providing care, treatment, consultation, pharmaceuticals or supplies or;

• An insurance carrier or group health plan.

Health information requested or disclosed may include, but is not limited to: claims records, correspondence, medical records, billing statements, diagnostic imaging reports, laboratory reports, dental records, or hospital records (including nursing records and progress notes).

I affirm the answers in this “Dental Choice/Dental Choice Plus Individual Enrollment Application” are complete and correct. I am providing these answers as part of the application procedure required by this insurance carrier to enroll in its insurance coverage. I understand that the insurance carrier will rely on each answer in making its determination to extend coverage and to determine the type of coverage offered. I understand if I have made any misstatement or omission in this application, the insurance carrier may take any action available by law, including but not limited to, retroactive adjustment of premiums or claims. Further, I understand that any fraud or intentional misrepresentation of material fact in my completion of this application is cause for retroactive termination of coverage by the insurance carrier and/or other action available at law. I will promptly inform the insurance carrier in writing if anything happens before my coverage takes effect that makes an answer on this application incomplete or incorrect. Following receipt of a fully-executed application, coverage will be in force as of the effective date determined by the insurance carrier under applicable law.

___________________________________________________ __________________

Applicant/Responsible Party Signature Date

___________________________________________________ __________________

Spouse’s Signature (if applying for coverage) Date

Independent Producer (Agent) InformationAgent’s Name Blue Cross of Idaho No.

Signature of Agent Date (mm/dd/yy)

For Office Use Only Electronic System ID

Form No. 3-189A (09-16)

Form No. 3-189 (09-16)

2017 Dental Choice &

Dental Choice Plus Individual Dental plans that meet Affordable Care Act requirements

One mission: you

Meridian3000 E. Pine Ave.

Meridian, ID 83642

Lewiston866-841-2583208-746-0531

Pocatello275 S. 5th Ave.

Pocatello, ID 83201208-232-6206

Twin Falls1503 Blue Lakes Blvd. N.

Twin Falls, ID 83301208-733-7258

Idaho Falls1910 Channing Way

Idaho Falls, ID 83404208-522-8813

Coeur d’Alene1450 NW Blvd., Suite 106 Coeur d’Alene, ID 83814

208-666-1495

Blue Cross of IdahoSales 888-462-7677

Customer Service 800-365-2345Claims Inquiries 208-331-7347

800-627-1188

bcidaho.com

One mission: you


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e an

d is m

aking

app

lication

for h

ealth coverag

e with

my fu

ll kno

wled

ge an

d co

nsen

t. I hereb

y accept fu

ll respo

nsib

ility for th

e paym

ent o

f prem

ium

s an

d th

e answ

ers and

info

rmatio

n p

rovided

in th

is app

lication

.

Print N

ame _______________________________________________________________________________________D

ate (mm

/dd/yyyy) __________________A

dd

ress (if different than dependent) _________________________________________________________________

Statem

ent o

f Un

derstan

din

gB

y sign

ing

this ap

plicatio

n, I rep

resent th

at all my an

swers are co

mp

lete an

d accu

rate to th

e best o

f my kn

ow

ledg

e and

belief an

d th

at I u

nd

erstand

and

agree to

the fo

llow

ing

con

ditio

ns:

•N

o independent producer, agent or employee of the insurance carrier can change

any part of this application or waive the requirem

ent that I answer all questions

completely and accurately.

•T he insurance carrier m

ay terminate or rescind an insured’s coverage for any

intentional misrepresentation, om

ission of fact by, concerning or on behalf of anyinsured that w

as or would have been m

aterial to the insurance carrier’s acceptance ofa risk, extension of coverage, provision of benefits, or paym

ent of any claim.

•If this application is appro ved, coverage for m

e and any eligible persons named on this

application will begin on the effective date assigned by the insurance carrier.

•I understand that this application w

ill become part of the contract betw

een theinsurance carrier and m

e.•

I affirm that I have review

ed all answers given on this application and, regardless of

whether an independent producer or other person has filled out the answ

ers for me, I

verify that the answers are true and com

plete.I ackn

ow

ledg

e and

un

derstan

d m

y health

plan

may req

uest o

r disclo

se h

ealth in

form

ation

abo

ut m

e or m

y dep

end

ents (p

erson

s wh

o are elig

ible

for b

enefits coverag

e and

are listed o

n th

e app

lication

) for th

e pu

rpo

se of

facilitating

health

care treatmen

t, paym

ent o

r for th

e pu

rpo

se of b

usin

ess o

peratio

ns n

ecessary to ad

min

ister health

care ben

efits; or as req

uired

by

law.

Health

info

rmatio

n req

uested

or d

isclosed

may b

e related to

treatmen

t or

services perfo

rmed

by:

•A

physician, dentist, pharmacist or other physical or behavioral healthcare practitioner;

•A

clinic, hospital, long-term care or other m

edical facility;•

Any other institution providing care, treatm

ent, consultation, pharmaceuticals or

supplies or;•

An insurance carrier or group health plan.

Health

info

rmatio

n req

uested

or d

isclosed

may in

clud

e, bu

t is no

t limited

to: claim

s record

s, corresp

on

den

ce, med

ical record

s, billin

g statem

ents,

diag

no

stic imag

ing

repo

rts, labo

ratory rep

orts, d

ental reco

rds, o

r ho

spital

record

s (inclu

din

g n

ursin

g reco

rds an

d p

rog

ress no

tes).

I affirm th

e answ

ers in th

is “Den

tal Ch

oice/D

ental C

ho

ice Plu

s Ind

ividu

al E

nro

llmen

t Ap

plicatio

n” are com

plete an

d co

rrect. I am p

rovidin

g

these an

swers as p

art of th

e app

lication

pro

cedu

re requ

ired by th

is in

suran

ce carrier to en

roll in

its insu

rance coverage. I u

nd

erstand

th

at the in

suran

ce carrier will rely o

n each

answ

er in m

aking

its d

etermin

ation

to exten

d coverage an

d to

determ

ine th

e type o

f coverage o

ffered. I u

nd

erstand

if I have m

ade any m

isstatemen

t or

om

ission

in th

is app

lication

, the in

suran

ce carrier may take any actio

n

available by law

, inclu

din

g b

ut n

ot lim

ited to, retro

active adju

stmen

t of

prem

ium

s or claim

s. Furth

er, I un

derstan

d th

at any fraud

or in

tentio

nal

misrep

resentatio

n o

f material fact in

my co

mp

letion

of th

is app

lication

is cau

se for retro

active termin

ation

of coverage by th

e insu

rance carrier

and

/or o

ther actio

n availab

le at law. I w

ill pro

mp

tly info

rm th

e insu

rance

carrier in w

riting

if anythin

g h

app

ens b

efore m

y coverage takes effect th

at makes an

answ

er on

this ap

plicatio

n in

com

plete o

r inco

rrect. Fo

llowin

g receip

t of a fu

lly-executed

app

lication

, coverage will b

e in

force as o

f the effective d

ate determ

ined

by the in

suran

ce carrier un

der

app

licable law

.

_____________________________________________ ________________

Ap

plican

t/Resp

on

sible Party S

ign

ature

Date

_____________________________________________ ________________

Sp

ou

se’s Sig

natu

re (if applying for coverage) D

ate

Ind

epen

den

t Pro

du

cer (Agen

t) Info

rmatio

nA

gent’s N

ame

Blu

e Cro

ss of Id

aho

No.

Sig

natu

re of A

gent

Date (m

m/d

d/yy)

For O

ffice U

se On

lyE

lectron

ic System

ID

Form N

o. 3-189A (09-16)

18-080-01/17 18-081-01/17

Policy Form Numbers: 18-079-01/17

Documents

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