Collected Rules and Regulations

Benefit Plans

Chapter 500: Benefits Program Plans

510.010 Dental Benefits Plan

Bd. Min. 11-13-81; Amended Bd. Min. 12-7-84, 7-15-86, 12-12-86, 1-1-85, 12-8-89, 6-22-90, 6-14-91 and 10-23-91. Amendment DEN-1 and DEN-2 effective 10-15-96; DEN-3 and DEN-4 effective 1-1-98; DEN-5 and DEN-6 effective 1-1-00; DEN-7 effective 9-1-01; DEN-8 effective 5-1-01; DEN-9 effective 6-1-01; DEN-10 effective 4-1-03; DEN-11 effective 1-1-04; DEN-12 effective 1-1-05. DEN-13 effective 1-1-07; DEN-14 effective 1-1-07.

1. Introduction -- This document constitutes the University of Missouri Dental Plan. It is intended to constitute a separate, written Plan for the exclusive Benefit of the Participants of the University and to provide such Participants with dental Benefits. This Plan is established and shall be maintained with the intention of qualifying it as an accident or health Plan under Section 105 of the Internal Revenue Code, and its terms are to be interpreted in a manner consistent with the requirements of such Section.
    
2. Definitions -- For purposes of the Plan, the following words and phrases, whether or not capitalized, shall have the respective meaning herein provided, unless different meanings are plainly indicated by the context.
   1. "Active Work on a Full-Time Basis"-- means an Employee is performing all of the essential functions of a job at the usual place of employment or at a place designated by the University. It shall also refer to any Employee on vacation or on leave of absence or for any reason other than temporary layoff not at the regular place of employment. This definition will not act to defer coverage for an Employee who is not Actively at Work due to a Health Factor;
   2. "Benefit" -- means the payment or reimbursement by the Plan of a dental expense incurred by a Participant.
   3. "Child or Children" --
      1. Child or Children means unmarried:

         1) natural children

         2) stepchildren or foster Children who live with the Employee or Retired Employee (except during a period in which the Child is enrolled at an accredited education institution on a full-time basis) in a normal parent-Child relation;

         3) legally adopted Children or Children placed in the Employee's or Retired Employee's home for adoption;

         4) each Child, who other wise meets the definition of "Child" under the Plan, of an Employee for whom the University has received a valid Notice of Order to Enroll and for which the University is obligated to comply under Senate Bill No. 253 which repeals various Sections of RSMO 1986 and RSMO Supp. 1992.

      2. Dependent Children must meet additional requirements, as specified in the definition of Dependent, in order to be eligible to participate in this Plan.
      3. For the purpose of the Plan, foster Children means Children for whom the Employee or Retired Employee and the Employee's or Retired Employee's Spouse have assumed legal duty and Children related to the Employee or Retired Employee or the Employee's or Retired Employee's Spouse by blood or by marriage. Foster Children do not include:

         1) Children temporarily living in the Employee's or Retired Employee's home;

         2) Children placed in the Employee's or Retired Employee's home by a social service agency which retains control of the Children, or

         3) Children whose natural parents or parents are in a position to exercise or share parental responsibility and control.

   4. "Claims Service Contractor" -- means the person(s) or entity(ies) engaged by the University to perform certain duties related to payment of Benefits.
   5. "Continuation Coverage" -- means the coverage elected by a Qualified Beneficiary as a result of a Qualifying Event consistent with the requirements of Section 4980B of the Code. If the provisions of this Plan are modified for similarly situated beneficiaries, such coverage shall also be modified in the same manner for all Qualified Beneficiaries as of the same date.
   6. "Continuation Premium" -- means the amount of Contribution required for participation by a Qualified Beneficiary for Continuation Coverage.
   7. "Covered Dental Expense" -- means only expenses incurred for Type A, Type B or Type C Dental Expenses as described in Section 510.010.D. if:
      1. they are needed and customary;
      2. they are not more than customary charges for like care or supplies (as determined by the University);
      3. they are prescribed by a Doctor;
      4. they are not excluded by the exceptions; provided, however, that Covered Dental Expenses will be limited to the Reasonable and Customary charge for the services and supplies which are customarily employed nationwide for the treatment of the condition involved and which are recognized by the dental profession to be appropriate methods of treatment in accordance with broadly accepted national standards of dental practice, taking into account the total current oral condition of the Employee, or Dependent, involved.
             In deciding if expenses are customary and treatment and services are needed, the University will judge the fees normally charged for like cases in that area. "Area" means a region (determined by the University) large enough to get a cross Section of providers of dental care or supplies.
            The University will consider expenses to be incurred on the date the care or supply is received.
   8. "Doctor" -- means one licensed to practice dentistry or a legally qualified physician or surgeon;
   9. "Dependent" -- means the following persons who are not eligible as Employees or Retired Employees and are not in active duty in the armed forces:
      1. the Spouse of an Employee or Retired Employee;
      2. each Child of an Employee or Retired Employee through the day before such Child reaches 19 years of age;
      3. each Child of an Employee or Retired Employee who is receiving Principal Support from the Employee or Retired Employee or the Employee's or Retiree's Spouse through the day before such Child reaches age 23;
      4. each Child of an Employee or Retired Employee who is a full-time student at, and as determined by, an accredited education institution and receiving Principal Support from the Employee or Retired Employee or such Employee's or Retired Employee's Spouse though the day before such Child ceases to be a full-time student, but in no event beyond the day before such Child reaches 25 years of age;
      5. each Child of an Employee or Retired Employee who is mentally or physically incapable of earning a living due to such disability existing at the time such Child reached the maximum age provided in B., c., or d. above. Application for continuation of Dependent status for such Child must be made with the Plan Administrator thirty-one days prior to the Child's attaining such maximum age. The Plan Administrator has the right to require proof of the continuation of such disability upon attainment of such age as often as deemed necessary by the Plan Administrator, but in any event not less than once a year. If the Employee or Retired Employee fails to submit such proof, coverage shall be discontinued thirty-one days after the Plan Administrator requested such proof.
             Only those individuals who satisfy the definition of a Dependent of a Retired Employee, as described herein, as of the day next preceding retirement, will be eligible as a Dependent of a Retired Employee.
   10. "Employee" -- means an individual who:
       1. is considered full-time by the University, who is classified at least 75% full-time equivalence, with an indicated appointment duration of at least nine months (for the purpose of this section any individual who is simultaneously employed by the University and the Harry S. Truman Veterans Administration Hospital pursuant to an agreement between said organizations, and whose joint appointments, combined, otherwise meet the requirements of this section, shall be considered an Employee); and
       2. is paid out of University funds; and shall also include all other full-time Employees of the University, full-time to the University, and full-time Employees of other agencies or institutions attached to the University, but not an integral part of the University, or any of them, while designated by the University as entitled to be covered under this Plan; and
       3. performs the essential functions of the job at the usual place of employment or at a place designated by the University, and if advantageous to the Employee, shall include any full-time Employee on vacation or on leave of absence or for any reason other than temporary layoff not at the regular place of employment, provided the Employee is not disabled so as to be unable to perform all of the usual duties of the occupation; or
       4. was covered as an Employee and, while covered as a full-time Employee, became totally and permanently disabled in accordance with the University of Missouri's Long Term Disability Plan and is entitled to continued service credit as a disabled Employee under the University of Missouri's Retirement Disability and Death Benefit Plan.
              A "per diem employee" as defined in Section 320.050.I.A.3. of the University of Missouri Collected Rules and Regulations is excluded as an "Employee" under this Plan.
   11. "Health Factor" -- means an individual’s health status medical condition (including both physical and mental illnesses) claims experience, receipt of health care, medical history, evidence of insurability and disability.
   12. "Hospital" -- means:
       1. an acute care institution which is operated pursuant to state law and is primarily engaged in providing, on an In-patient basis, for the medical care and treatment or sick and injured persons through medical, diagnostic, and major surgical services, all of which services must be provided on its premises, and meets the standards below:

          1) has permanent and full-time care for bed patients;

          2) has a Doctor in regular attendance;

          3) provides twenty-four hour a day care by registered graduate nurses;

          4) is mainly engaged in giving medical care and services for injuries of illnesses but not including:

          • Rest homes;
          • Nursing homes;
          • Convalescent homes;
          • Facility for the aged, or extended care facility;
          • Skilled nursing facility;
          • Facilities used primarily for rehabilitative services or physical therapy services;
       2. An institution not meeting all of the foregoing requirements but which meets state licensing requirements and is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals.
       3. Hospital also means and will include an ambulatory surgical center which meets all of the standards below:

          1) is operated pursuant to state law;

          2) has an organized medical staff of Doctors;

          3) has permanent facilities that are equipped and operated mainly for doing Surgery;

          4) has registered graduate nurse services when a patient is in the facility; and

          5) does not provide services or beds for patients to stay overnight.

   13. "Medically Necessary and Appropriate" -- means:
       1. required for the symptoms or diagnosis associated with the surgical procedure of the Participant;
       2. provided in the facility, setting or environment which can provide the most appropriate and cost effective level of care for the Participant.
       3. determined in the judgement of the Claims Service Contractor to be within acceptable standards of medical practice for the specific Participant.
   14. "Participant" -- means any Employee or Retired Employee or their Dependents who has enrolled or been enrolled to participate in the Plan in accordance with the provisions of Section 510.010.C.
   15. "Principal Support" -- means that an Employee or Retired Employee during the calendar year is continuously providing more than one half of the support of a Child, including the amount spent to provide food, lodging, clothing, education, medical, dental and vision care, recreation, transportation and similar necessities.
   16. "Qualified Beneficiary" -- means a Participant or a covered Dependent of a Participant covered under this Plan on the day prior to the Qualifying Event.
   17. "Qualifying Event" -- means any of the following events which would otherwise result in a loss of coverage for a Qualified Beneficiary in the absence of this provision:
       1. termination of employment, for any reason other than gross misconduct;
       2. reduction in work hours so as to render the Employee ineligible for coverage;
       3. divorce or legal separation;
       4. ceasing to qualify as a Dependent under the provisions of this Plan;
       5. covered Employee's entitlement to Benefits under Medicare; or
       6. death of an Employee
   18. "Qualifying Family/Employment Status Change" -- means a change in family or employment status as a result of any of the following:
       1. change in legal marital status, including marriage, divorce, legal separation or annulment, or death of spouse;
       2. change in the number of Dependent Children who are eligible for coverage under this plan as a result of death, birth, adoption or placement of a Child for adoption, or a Child ceasing to be eligible or becoming eligible in accordance with the definitions of Child or Children and Dependent;
       3. change in the employment status of the Employee or Spouse which involves the commencement or termination of employment;
       4. change in the work schedule of the Employee or Spouse which involves an increase or decrease in work hours, a strike, a lockout or an unpaid leave of absence;
       5. issuance to the University of a valid Notice of Order to Enroll, as described in the definition of Child or Children;
       6. rehiring of an Employee by the University during the same year in which the Employee previously terminated employment by the University;
       7. with respect only to an Employee who specifically declined coverage under this plan as a result of the existence of other coverage, as described in 510.010.C.2.c, a special enrollment period will be available to such Employee in the event such other coverage ends, as described in said Section 510.010.C.2.c;
       8. significant change in health coverage of the Employee or Spouse attributable to the Spouse’s employment;
       9. significant change in the cost of coverage under a health plan; and
       10. leave of absence under the Family and Medical Leave Act of 1993 (FMLA).
   19. "Reasonable and Customary Charges" -- means charges for dental services, treatments, or supplies essential to the care of the individual which are the lesser of:
       1. actual charges for such services, treatments, or supplies; or
       2. the amount normally charged for comparable services, treatments, or supplies by most providers in the locality at the time incurred, where the charges were incurred when furnished to a similarly situated individual.
   20. "Retired Employee" -- means any individual who was covered as an Employee of the University and who has been or will be at any future date, retired by the University as a qualified disabled or Retired Employee under the terms and provisions of the University of Missouri Retirement Disability and Death Benefit Plan maintained by the University provided that said individual was covered under this Plan as an Employee of the University on the date preceding retirement. A Retired Employee shall also mean a Surviving Spouse.
   21. "Spouse or Surviving Spouse" -- means:
       1. Spouse:

          1) the legal Spouse of an Employee, other than a deceased Employee, excluding a divorced Spouse or a Spouse separated by contract or decree from the Employee;

          2) the Surviving Spouse of a deceased Employee or Retired Employee, excluding a divorced Spouse or a Spouse separated by contract or decree from the Employee;

          3) the legal Spouse of a Retired Employee to whom the Retired Employee was married on the day next preceding retirement.

       2. Surviving Spouse:

          1) a Spouse covered as a Surviving Spouse under the policy of group insurance which is superseded by this Plan on March 31, 1963 in accordance with the provisions of said policy in effect on said date; or

          2) the Spouse to whom an Employee or Retired Employee who dies on or after January 1, 1970 with five years or more of full-time employment and who would meet the vesting requirements of the University of Missouri Retirement Disability and Death Plan; or is married on the date of the death, provided such Spouse was married to such Employee or Retired Employee for at least one year and, in addition, in the case of a Retired Employee who dies after retirement, provided such Spouse was married to the Retired Employee on such date next preceding retirement.

   22. "University" -- means The Curators of the University of Missouri, a public corporation, including all of its divisions, branches and parts.
        
3. Eligibility and Participation
   1. Employee Eligibility -- Employees are eligible to participate in this Plan on the first day they are employed. Any person who is not an Employee by reason of being employed on a part-time or temporary basis or who would be an Employee except for the fact that the individual is not designated by the University as entitled to Benefits, but who subsequently becomes an Employee by reason of a change from part-time to full-time or temporary to permanent employment or by reason of designation of the University, shall be eligible to participate in this Plan on the effective date of such change of designation.
          An Employee may become covered in the Plan by making written application for such coverage on forms prescribed by the University for that purpose, and by making the required contribution for such coverage.
   2. Employee Participation
      1. An Employee becomes a Participant in the Plan on the date the Employee becomes eligible to participate, provided:

         1) the Employee makes written application for coverage under this Plan on or before becoming eligible to participate and is then employed by the University; or

         2) the Employee makes written application after the date the Employee becomes eligible to participate, but not more than thirty days after such date or not more than thirty days after return to active employment if the Employee was not Actively at Work on the date of eligibility. Such coverage will become effective on the date the Employee becomes eligible to participate provided the application is received by the Faculty & Staff Benefits Office of the University within 30 days of the date the Employee becomes eligible to participate.

      2. An Employee who is not Actively at Work when the Employee would otherwise become a Participant shall become a Participant on the date of the Employee's return to Active Employment.
             In the case of an Employee who is not Actively at Work due to a Health Factor on the date the Employee would otherwise become a Participant, the date the Employee becomes a Participant will be determined without regard to the fact that the Employee was not Actively at Work.
      3. If an Employee:

         1) elects not to become a Participant or does not make written application within the period applicable to the Employee in the preceding paragraph; or

         2) an Employee's participation ceased because of failure to make the required contributions to the University and the Employee makes a subsequent application to participate; then such Employee may subsequently become a Participant as of the first day of the year coincident with or next following the date the Employee makes written application, subject to the limitation described in Section 510.010.E.1.d, unless

         i) the Employee had specifically declined coverage previously, and

         ii) the reason for such declination was because the Employee already had similar coverage, and

         iii) the other coverage ended, and

         iv) the Employees’ written application for participation is received by the Faculty & Staff Benefits Office of the University within 31 days of the date the other coverage ended, in which case such Employee shall be eligible to become a Participant under a “special enrollment period” on the first day of the month following the date the application for participation was received as described above.

      4. In no event shall an Employee become a Participant prior to the beginning date of employment with the University.
   3. Retired Employee Eligibility -- A Retired Employee remains eligible to participate in the Plan as long as the Retired Employee is entitled to receive Benefits immediately upon retirement under the University of Missouri Retirement Disability and Death Benefit Plan or those Retired Employees who would be entitled to receive such Benefits had they not elected to participate in a federal or state government retirement program.
   4. Dependent Eligibility -- A Dependent of an Employee is eligible to participate in the Plan on the later of:
      1. the date such Employee becomes a Participant; or
      2. the date the person becomes a Dependent of a participating Employee.
             The Surviving Spouse of an Employee who dies on or after January 1, 1970, and who has completed five years or more of creditable service, as defined under the University of Missouri Retirement Disability and Death Benefit Plan, is eligible to participate, if such Spouse had been married to the Employee for one year or more (and, in addition, in the case of a Retired Employee who dies after retirement, if the Spouse was married to him on the day next preceding his retirement), provided the Spouse was a Participant on the date of his death. His Dependent Children may participate, if they were participating on the date of his death, provided the Spouse makes written application for coverage for herself and for such Dependent Children within thirty-one days after the date of the Employee's or Retired Employee's death. Should a Retired Employee terminate coverage for a Dependent, that Dependent is no longer eligible to be a Participant as a Dependent of said Retired Employee.
             In those cases where a Surviving Spouse who is entitled to Benefits remarries a Retired Employee, the Surviving Spouse may forfeit all entitlement to Benefits under the Plan resulting from the previous marriage, and shall immediately be entitled to Benefits based on the Benefits which the Retired Employee in the remarriage was entitled to receive under the Plan.
            If the Spouse does not survive the Employee or Retired Employee, none of the Dependent Children shall be eligible to participate after the Employee's or Retired Employee's death.
            The estate of the deceased Employee or Retired Employee shall have no interest in any Benefits payable with respect to any charges incurred by a Dependent after the death of the Employee or Retired Employee.
   5. Dependent Participation
      1. A Dependent becomes a Participant as follows:

         1) on the same date that the Employee becomes a Participant, provided the Employee makes written application for such Dependent on or prior to the date the Employee became eligible to participate, subject to the provisions of 510.010.C.5.b, or

         2) on the date that the Employee makes written application, or the date such Employee becomes a Participant, whichever is later, provided such Employee makes such written application for such Dependent after the date on which the Dependent becomes eligible but not more than thirty-one days following the date of the Employee's return to work if the Employee is not Actively at Work, if later, subject to the normal activity health requirements set forth below.

      2. If on the date on which a Dependent would otherwise participate hereunder such Dependent is then confined in a Hospital, or if the Dependent was so confined at any time during the period of thirty-one days ending with said date, the Dependent shall become a Participant on:

         1) the date following a continuous period of thirty-one days during all of which the Dependent carried on substantially the normal activities of a person of like age and sex in good health and was at no time so confined or under such care; or

         2) the date of approval by the University of satisfactory evidence of good health of that Dependent furnished by the Employee to the University without expense to it.
             However, such deferment of participation of that Dependent shall not operate to defer the participation of any other Dependent of the Employee, nor to defer the participation of a Child born while the Employee's Dependents are participating hereunder.

      3. An Employee may have Dependents participate hereunder only by making written application for such coverage on forms prescribed by the University for that purpose, and by making the required contribution.
      4. Even though an Employee has Dependent coverage, the Employee shall make written application to cover any additional Dependents acquired after the date such Dependent became a Participant. An Employee shall make specific written application to cover each such additional Dependent for whom the Employee wishes to provide Dependent coverage hereunder. Coverage will be provided only for those Dependents for whom the Employee has made such specific written application.
      5. Unless the Employee is eligible for the “special enrollment period” described in Section 510.010.C.2.c., an Employee who makes written application to cover a Dependent more than thirty-one days after the date the Dependent becomes eligible for coverage, and an Employee who reapplies for coverage after the coverage of Dependents has automatically ceased because of failure to make the required contribution, will be eligible to elect coverage as follows:

         1) When the Dependent for whom coverage is requested is the Spouse, such coverage will be subsequently provided as of the first day of the month coincident with, or next following the date the Employee makes application, subject to the limitations described in Section 510.010.E.1.d.

         2) When the Dependent for whom coverage is requested is a Child for whom specific additional Employee contribution is required, coverage for such Child will become effective on the first day of the month coincident with or next following the date the Employee makes written request to cover such Child, provided the request is made within one hundred and eighty (180) days of the date the Child first became eligible for such coverage and subject to the limitations described in Section 510.010.E.1.d. If the employee’s request for coverage is not received within this 180 day period the Employee may request coverage during the next subsequent enrollment period designated by the University, and coverage will become effective on the following January 1 and subject to the limitations described in Section 510.010.E.1.d.;

         3) When the Dependent for whom coverage is requested is a Child for whom specific additional Employee contribution is not required, such coverage will become effective on the date the Child was first eligible for such coverage.

      6. A Dependent, except in the case of a newborn Child or a Child placed in the custody of adopting parents under Missouri State Law, acquired after the date the Employee becomes a Participant, will become a Participant, on the date on which the written application is received by the University, provided it is received on or within thirty-one days of the date the Dependent was first acquired. In the case of a newborn Child, such Dependent shall become a Participant on the date of the Child's birth, provided that the application is received on or within thirty-one days of that date of birth. In the case of a Child placed for adoption, under Missouri State Law, the Dependent shall become a Participant on the date the Child was placed in the custody of the adopting parents provided that the application is received on or within thirty-one days of that date.
      7. Each Dependent who was covered under the group insurance superseded by this Plan on June 30, 1990, and who is eligible on July 1, 1990, shall continue to participate on or after July 1, 1990, subject to the terms and conditions of this Plan.
             If a Child or Children of an Employee are acquired while the Employee is participating but has no Dependent coverage on Children, such Child or Children shall become Participants from the date they become eligible to participate, subject to the normal activity health requirement in the case of Children other than newborn Children but subject to no health requirement with respect to newborn or adopted Children, provided the Employee makes the required written application to cover such Child or Children not later than thirty-one days after said date.
      8. If both the husband and wife are participating as Employees or Retired Employees and one Spouse ceases to participate by reason of a change in employment status from a full-time Employee to a status other than a full-time Employee or by reason of a change in the designation of the University, the Spouse's coverage as a Dependent shall become effective on the date the Spouse becomes eligible as a Dependent, provided the Employee or Retired Employee makes the required written application to cover the Spouse not more than thirty-one days after said date.
      9. If both the husband and wife participate as Employees or Retired Employees and one has Children participating as Dependents, and if the Employee ceases to participate for any cause, the coverage on such Children shall continue in effect without interruption provided they are Dependents of the Spouse and provided the Spouse makes the required written application for such coverage within thirty-one days after the cessation of coverage of the other Spouse.
      10. No Dependent Benefits shall be payable to an Employee or Retired Employee with respect to any covered expenses if the Dependent is entitled to Employee or Retired Employee Benefits with respect to such covered expense by reason of having been covered for Benefits under this Plan as an Employee or Retired Employee.
      11. Except in the case of a Qualifying Family/Employment Status Change, an Employee may change his or her participation status with respect to Dependents only during the enrollment period designated by the University. In the case of a Qualifying Family/Employment Status Change, the Employee may change such participation status by completing the required enrollment form and returning it to the Faculty & Staff Benefits Office of the University within 31 days of the date of the Qualifying Family/Employment Status Change, in which case the change will become effective as follows:

          1) in the case of a participation change involving the number of eligible Dependents, the change will become effective on the date of marriage, divorce, legal separation or annulment, death, birth or adoption or placement of a child for adoption, as applicable, and

          2) in the case of any other change, on the date the required change form is received by the Faculty & Staff Benefits Office of the University.

   6. Termination of Eligibility -- An Employee's or Retired Employee's Plan eligibility terminates on the day on which the Employee or Retired Employee ceases to meet the eligibility requirements of this Section. A Dependent of an Employee or Retired Employee will cease to be eligible for the Plan on the earlier of the date the Employee or Retired Employee's eligibility terminates or the date the Dependent no longer meets the requirements of Dependent status.
   7. Termination of Participation -- Plan participation will terminate for a Participant upon the first to occur of the following:
      1. the first day of the month following date of termination of employment of the Participant, provided, however for the purposes of coverage under this Plan;

         1) if an Employee ceases work because of illness or injury, employment shall be deemed to continue until terminated by the University, acting in accordance with principles which preclude individual selection;

         2) if an Employee ceases work, pursuant to a leave of absence granted in the usual course of the University's business, employment shall be deemed to continue during such leave or leaves of absence;

         3) if an Employee suspends coverage while on an approved leave of absence, upon return from leave and within 31 days, the Employee can resume enrollment in the Plan;

      2. the end of the period for which required Contributions have been paid; or
      3. the date the Plan terminates.
             Once Plan participation has been terminated for a Retired Employee, a Dependent of a Retired Employee or Surviving Spouse Participant, such individual may not elect to participate again at any future date, unless otherwise eligible for coverage as an Employee or a Dependent of an Employee.
       
4. Dental Benefits
   1. Benefits are payable under this Plan for Covered Dental Expenses which are incurred while the Participant is covered under this Plan, which are described as Type A Expenses, Type B Expenses, or Type C Expenses provided such expenses are not excluded.
   2. Type A Dental Expenses means only:
      1. Oral examinations, including prophylaxis (scaling and cleaning of teeth), but not more than twice in any calendar year;
      2. Topical application of fluoride, but only for covered individuals under 19 years of age, twice per calendar year;
      3. Emergency palliative treatment;
      4. Space maintainers that replace prematurely lost teeth for Children under 19 years of age;
      5. Dental x-rays required in connection with the diagnosis of a specific condition requiring treatment. Also other dental x-rays, but not more than one full mouth x-ray or series in any period of 36 consecutive months and not more than two sets of supplementary bitewing x-rays in any calendar year.
      6. Sealants, but only for covered individuals under 16 years of age.
   3. Type B Dental Expenses means only:
      1. Extractions;
      2. Oral surgery, including surgical extractions; provided such surgery is not covered under the medical Benefits Plan provided by the University;
      3. Fillings;
      4. General anesthetics when medically necessary and administered in connection with oral surgery or other covered dental services;
      5. Treatment of periodontal and other diseases of the gums and tissues of the mouth;
      6. Endodontic treatment, including root canal therapy;
      7. Injection of antibiotic drugs;
      8. Repair or recementing crowns, inlays, onlays, bridgework or dentures; or adjusting, relining or rebasing of dentures more than 6 months after the installation of an initial or replacement denture, but not more than one relining or rebasing in any period of 36 consecutive months.
      9. Hospital services and supplies in connection with In-patient and Out-patient Hospital services when such services are Medically Necessary and Appropriate for a covered dental service, but only when the Participant is covered for medical Benefits under a medical Benefit program available through the University of Missouri Medical Benefits Plan which does not cover such Hospital services or supplies in connection with dental services. Any Benefits payable under this specific provision of the Dental Benefits Plan will not be subject to the $1,500 calendar year Dental Maximum for such Participant.
   4. Type C Dental Expenses means only:
      1. Inlays, onlays, gold fillings, or crown restorations to restore diseased or accidentally broken teeth, but only when the tooth, as a result of extensive decay or fracture, cannot be restored with an amalgam, silicate, acrylic, synthetic porcelain or composite filling;
      2. Initial installation of fixed bridgework (including inlays and crowns as abutments);
      3. Initial installation of partial or full removable dentures (including adjustments for the 6 month period following installation);
      4. Replacement of an existing partial denture or fixed bridgework by new fixed bridgework, or the addition of teeth to existing fixed bridgework. However, only replacements and additions that meet the "Prosthesis Replacement Rule" below will be covered.
             The "Prothesis Replacement Rule" requires that replacements or additions to existing dentures or bridgework will be covered only if evidence satisfactory to the University is furnished that one of the following applies:

         1) The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed; or

         2) The existing denture or bridgework cannot be made serviceable and was installed at least 5 years prior to its replacement; or

         3) The existing denture is an immediate temporary which cannot be made permanent and replacement by a permanent denture is required and takes place within 12 months from the date of initial installation of the immediate temporary denture.

   5. Deductible Requirement
      1. A deductible applies each calendar year to Type B and Type C Covered Dental Expenses shown in the Schedule. Such requirement is met as soon as Type B and Type C Covered Dental Expenses in a Plan year equal the Deductible shown in the Schedule. Such expenses must be incurred while covered, in a period of time not to exceed the Deductible Accumulation Period.
      2. The Deductible Accumulation Period begins on the date the first Covered Type B and Type C Dental Expense used to meet the deductible requirement is incurred and continues through the calendar year in which the first covered Type B and Type C Covered Dental Expenses were incurred.
      3. If, during one calendar year, the Type B and Type C Covered Dental Expenses incurred by the covered individuals in one family are equal to the Family Deductible Limit shown in the Schedule, then the deductible shall be considered to have been met for all covered individuals of the family for the remainder of that calendar year.
   6. Benefit for Covered Dental Expenses
      1. The Benefits payable is shown in the Schedule provided:

         1) If a deductible requirement applies, Benefits are not payable for expenses used to satisfy the deductible;

         2) The total amount payable for a covered individual shall not exceed the Dental Maximum shown in the Schedule.

   7. Pre-Estimation of Benefits
      1. Pre-estimation of dental Benefits is available to a covered individual when the estimated amount of charges will be $200 or more. The covered individual may ask the University to review the dentist's proposed course of treatment and estimated charges before the treatment begins. The University will tell the covered individual and the dentist what expenses are covered and the amount of Benefits that will be paid.
      2. A pre-estimation of Benefits does not have to be requested. If it is not requested, the University will determine the Benefits upon receipt of the proof of claim.
      3. If treatment Plan for pre-estimation of Benefits was submitted and later changed, the University will adjust the amount of Benefits to be paid. If a major change in the treatment Plan is made, a revised Plan should be submitted to the University. The University will make a revised estimate of the amount of Benefits to be paid.
       
5. Exclusions
   1. This Plan does not cover:
      1. Any dental care or supplies which are not included in the definition of Covered Dental Expense;
      2. Dental care or supplies which are furnished in a facility operated under the direction of or at the expense of the U.S. Government (or its Agency) or by a Doctor employed by such a facility and for which no payment would be required if the covered individual did not have this coverage;
      3. Dental care and supplies for which:

         1) No charge is made;

         2) No payment would be required if the covered individual did not have this coverage;

         3) Dental care or supplies due to sickness covered by Workers' Compensation, Occupational Disease Law or similar laws; or injury if it arises out of or during the course of employment for pay, profit or gain;

         4) Dental care or supplies to the extent that they are payable under other provisions of the Plan or under any other Plan of Benefits provided by the University;

         5) Dental care or supplies as a result of:

         a) Act of war (declared or undeclared)

         b) Insurrection;

         6) Charges for replacement of a lost, missing or stolen prosthetic device;

         7) Supplies for dental care other than those used in a Doctor's office; or instructions in dental hygiene;

         8) Oral care and supplies which are used to change vertical dimension or closure. These include but shall not be limited to:

         a) Procedures used for diagnosis

         b) Procedures used for balance

         c) Restoration

         d) Devices

         e) Movable devices

         f) Orthodontics

         9) Charges for dietary instruction on plaque control programs;

         10) Charges for failure to keep a scheduled visit:

         11) Charges for the completion of a claim form;

         12) Charges for services or supplies that are cosmetic in nature, including charges for personalization or characterization of dentures;

         13) Charges for services or supplies which are experimental in nature;

         14) Charges in connection with orthodontics.

       
6. Extended Dental Benefits
   1. If a course of treatment has been established for:
      1. dentures,
      2. fixed bridgework, or
      3. crowns and the individual's coverage is terminated, coverage in connection with any treatment shown above will be considered to be expenses incurred when ordered, but only if the item is finally installed or delivered no later than 60 days after termination of coverage.
   2. If a covered individual is totally disabled, as defined herein, on the date such individual's coverage terminates, dental Benefits will still be payable subject to the following:
      1. The dental care, services or supplies are given and received, including delivered and installed, if applicable, within twelve months after this Benefit terminates; and
      2. The individual does not become covered under any group Plan with similar Benefits.
   3. As used herein, "totally disabled," means:
      1. That an Employee is unable to perform regular work because of injury or sickness;
      2. That any other covered individual is prevented from engaging in all normal pursuits of other people of the same age and sex and in good health because of injury or sickness.
       
7. Coordination of Benefits
   1. Purpose -- As it is not the intent nor purpose of this Plan for Benefits thereunder to be paid to a Participant greater than the actual amount of expenses incurred, the Plan will take into account any coverage such Participant has under other Plans as specified below. This Section describes the coordination of Benefit payments from different sources.
   2. Definitions
      1. Solely for purposes of this Section, Plan means any Plan providing Benefits or services for or by reason of medical or dental care or treatment, which Benefits or services are provided by (1) a group, blanket or franchise Plan on an insured basis, (2) other Plan which covers people as a group; (3) a self-insured or non-insured Plan or other Plan which is arranged through an employer, Trustee or union; (4) a pre-payment Plan which provides medical, dental or health service; (5) government Plans, except Medicaid; (6) group auto insurance; (7) no-fault auto insurance on an individual basis except where not allowed by the state in which this Plan is issued; (8) single or family subscribed Plans issued under a group, blanket or franchise type Plan; but the term Plan shall not include any individual policies and Hospital indemnity Plans.
             The term Plan shall be construed separately with respect to each policy, contract or other arrangement for Benefits or services and separately with respect to that portion of any such policy, contract or other arrangement which reserves the right to take the Benefits or services of other Plans into consideration in determining its Benefits and that portion which does not.
      2. Solely for purposes of this Section, this Plan means the Dental Benefits Plan.
      3. Solely for purposes of this Section, Allowable Expense means any necessary, Reasonable and Customary item of expense at least a portion of which is covered under at least one of the Plans covering the person for whom claim is made.
             When a Plan provides Benefits in the form of services, rather than cash payments, the reasonable cash value of each service rendered shall be deemed to be both an Allowable Expense and a Benefit paid.
      4. Solely for purposes of this Section, Claim Determination Period means calendar year, except that if in any calendar year the person is not covered under this Plan for the full calendar year, the Claim Determination Period for that year shall be that portion thereof during which the person was covered under this Plan.
      5. Solely for purposes of this Section, when Benefits are reduced under a primary Plan because a Participant does not comply with the Plan provisions, the amount of this reduction will not be considered an Allowable Expense. Examples of these provisions are those related to second surgical opinion, Precertification and Hospital confinement review.
   3. Effect on Benefits
      1. This Section shall apply in determining the Benefits as to a Participant covered under this Plan for any Claim Determination Period for the Allowable Expenses incurred as to such a Participant during such Claim Determination Period.

         1) As to any Claim Determination Period with respect to which this Section is applicable, this Plan, in absence of this Section, will pay either its Benefits in full as determined under the applicable provision of this Plan or Benefits shall be reduced to the extent necessary so that the sum of such reduced Benefits payable for such Allowable Expenses under all other Plans, shall not exceed the total of such Allowable Expenses. Benefits payable under another Plan include the Benefits that would have been payable had claim been duly made therefore.

         2) If:

         a) Another Plan which is involved in (a) (1) above and which contains a provision coordinating its Benefits with those of this Plan would, according to its rules, determine its Benefits after the Benefits of this Plan have been determined, and

         b) The rules set forth in (c) immediately below would require this Plan to determine its Benefits before such other Plan, then the Benefits of such other Plan will be ignored for the purposes of determining the Benefits under this Plan.

         c) The rules establishing the order of Benefit determination are:

         i) The Benefits of a Plan which covers the Participant on whose expenses claim is based other than as a Dependent shall be determined before the Benefits of a Plan which covers such Participant as a Dependent;

         ii) The Benefits of a Plan which covers the Participant on whom claim is based is a Dependent of the parent whose month and day of birth occurs earlier in a calendar year shall be determined before the Benefits of a Plan which covers such Participant as a Dependent of the parent whose month and day of birth occurs later in a calendar year.

         iii) When the parents are separated or divorced and the parent with custody of the Child has not remarried, the Benefits of a Plan which covers the Child as a Dependent of the parent with custody of the Child will be determined before the Benefits of a Plan which covers a Dependent of the Plan without custody;

         iv) When the parents are divorced and the parent with custody of the Child has remarried, the Benefits of a Plan which covers the Child as a Dependent of the parent with custody shall be determined before the Benefits of a Plan which covers that Child as a Dependent of a stepparent. The Benefits of a Plan which covers that Child as a Dependent of the stepparent will be determined before the Benefits of a Plan which covers that Child as a Dependent of the parent without custody.

         v) Regardless of (iii) and (iv) above, if there is a court decree which would otherwise decide financial duty for the medical, vision, dental or health care expenses for such Child, the Benefits of a Plan which covers the Child as a Dependent of the parent for such financial duty shall be decided before the Benefits of any other Plan which covers the Child as a Dependent.

         vi) The Benefits of a Plan which covers a person as an Employee who is neither laid off nor retired (or as that Employee's Dependent) are determined before those of a Plan which covers that person as a laid off or Retired Employee (or as that Employee's Dependent). If the other Plan does not have this rule and if, as a result, the Plans do not agree on the order of Benefits, this rule is ignored.

         vii) When (i), (ii), (iii), (v) and (vi) above do not establish an order of Benefit determination, the Benefits of a Plan which has covered the Participant on whose expenses claim is based for the longer period of time shall be determined before the Benefits of a Plan which has covered such Participant the shorter period of time.

         viii) When this provision operates to reduce the total amount of Benefits otherwise payable as to a Participant of this Plan during any Claim Determination Period, each Benefit that would be payable in the absence of this Article shall be reduced proportionately and such reduced amount shall be charged against any applicable Benefit limit of this Plan.

   4. Right to Receive and Release Necessary Information -- For the purpose of determining the applicability of and implementing the terms of this Section of this Plan or any provision of similar purpose of any other Plan, the Claims Service Contractor may, without the consent of or notice to any person, release to or obtain from any other insurance company or other organization or person any information, with respect to any person, which the Claims Service Contractor deems to be necessary for such purposes.
          Any Participant claiming Benefits under this Plan shall furnish to the Claims Service Contractor such information as may be necessary to implement this Section.
   5. Facility of Payment -- Whenever payments which should have been made under this Plan in accordance with this Section have been paid under any other Plans, the Claims Service Contractor shall have the right exercisable alone and in its sole discretion, to pay over to any organizations making such other payments any amounts it shall determine to be warranted in order to satisfy the intent of this Section, and amounts so paid shall be deemed to be the Benefits paid under this Plan and, to the extent of such payments, the Claims Service Contractor shall be fully discharged from liability under this Plan.
   6. Right of Recovery -- Whenever payments have been made by the Claims Service Contractor with respect to Allowable Expenses in a total amount which is, at any time, in excess of the maximum amount of payment necessary at that time to satisfy the intent of this Section, the Claims Service Contractor shall have the right to recover such payments to the extent of such excess, from among one or more of the following, as the Claims Service Contractor shall determine: (a) any persons to or for or with respect to whom such payments were made, and (b) any other insurance companies or any other organizations.
       
8. Continuation of Coverage
   1. General -- The Benefits provided under the Plan may be continued for certain eligible Participants.
   2. Continuation Coverage -- Continuation Coverage may be available through Section 4980B of the Code, as amended from time to time.
          If a Qualified Beneficiary's coverage under this Plan terminates as a result of a Qualifying Event, such Qualified Beneficiary may elect Continuation Coverage, subject to payment of the Continuation Premium and the following provisions:
      1. If the loss of coverage is due to termination of employment or reduction in hours, Continuation Coverage may be elected for a period not to exceed eighteen months.
      2. If the loss of coverage is due to one of the other Qualifying Events, Continuation Coverage may be elected for a period not to exceed thirty-six months.
      3. Continuation Coverage can be extended beyond the eighteen-month period for an additional eleven months for Qualified Beneficiaries who, during the eighteen-month period, are determined to have been disabled for Social Security purposes at the time employment was terminated or working hours were reduced. The Qualified Beneficiary must notify the University of the disability within sixty days after the date of determination of the disability and before the eighteen-month continuation period expires.
      4. In the case of a legally separated, divorced or Surviving Spouse who is fifty-five years of age or older at the time of the expiration of coverage under Continuation Coverage, such continuation may be extended to the earlier of:

         1) failure to pay Continuation Premiums;

         2) termination of the Plan;

         3) the legally separated, divorced or Surviving Spouse becomes covered under any other group health Plan or remarries and becomes covered under any other group health Plan; or

         4) attainment of age sixty-five

      5. In the case of an Employee who becomes entitled to Medicare within the eighteen month period immediately preceding the Employee’s termination of employment or reduction in work hours that results in the Employee’s loss of coverage, the Dependents who are entitled to Continuation Coverage may elect such coverage for a period not to exceed eighteen months unless such eighteen month period would end prior to the expiration of thirty-six months from the date the Employee became entitled to Medicare, in which case Continuation Coverage for the Dependents will not exceed thirty-six months from the date the Employee became entitled to Medicare.
             The University shall be responsible for forwarding written notification of the rights for Continuation Coverage to the last known address of all Qualified Beneficiaries within thirty days of the date of the Qualifying Event, with the exception of the Qualifying Events described in Section 510.010.B.11 9 (c) and (d) of the definition of Qualifying Events. For these Qualifying Events, the Qualified Beneficiary shall be responsible for notifying the University of the occurrence of these Qualifying Events within sixty days of the date of such event. The University shall then have thirty days in which to forward written notification of the right to Continuation Coverage to the last known address of all Qualified Beneficiaries. Failure of the Qualified Beneficiary to notify the University of the occurrence of one of these Qualifying Events shall void the Qualified Beneficiary's right to Continuation Coverage.
   3. Election of Continuation Coverage -- Each Qualified Beneficiary shall have sixty days from the later of (i) the date Benefits would otherwise terminate, or (ii) the date notification is received from the University, to notify the University of the Qualified Beneficiaries' election for Continuation Coverage. The Qualified Beneficiary shall then have forty-five days following the date of such election to make all required Continuation Premiums, retroactive to the date of the Qualifying Event. Subsequent Continuation Premiums shall be considered timely and Continuation Coverage shall continue only if such Continuation Premiums are received within thirty-one days after the date such Continuation Premium is due. Continuation Premiums received after the thirty-one day grace period shall be considered nonpayment and Continuation Coverage shall terminate on the date ending the period for which the last Continuation Premium was made.
   4. Termination of Continuation Coverage -- Continuation Coverage shall terminate upon the earlier of:
      1. the expiration of the period of coverage as defined in Section 500.010.J.2;
      2. the date on which the University ceases to provide any dental Plan to any similarly situated beneficiary;
      3. the date on which timely Contributions are not received as required;
      4. the date on which the Qualified Beneficiary first becomes eligible for Benefits under Medicare;
      5. the date on which the Qualified Beneficiary first becomes covered under another group health Plan, as an Employee or otherwise, unless such other coverage contains an exclusion or limitation with respect to any existing condition or more restrictive Pre-Existing Condition of the Qualified Beneficiary. Then, coverage shall continue as long as the exclusion or limitation applies to the Qualified Beneficiary, but not longer than the eighteen month continuation period.
   5. Payment of Continuation Coverage -- The Qualified Beneficiary is responsible for paying all Continuation Premiums for the Continuation Coverage.
   6. Maintenance of Coverage with Respect to Participants on Leave Protected by the Family and Medical Leave Act of 1993 (FMLA Leave) and by the Uniformed Services Employment and Reemployment Rights Act of 1994 (Military Leave).
      1. Maintenance of Coverage under the Family and Medical Leave Act of 1993.

         1) A Participant who is on a leave of absence protected by the Family and Medical Leave Act of 1993 (FMLA Leave) may choose to maintain coverage, and the coverage of Dependents covered by the Plan on the day immediately prior to such leave for the duration of the FMLA Leave at the level and under the conditions that such coverage would have been provided if the Participant had continued Active Work. The Participant’s right to maintain such coverage shall end on the earliest of the following to occur:

         a) The date the Participant terminated employment by either notifying the University that the Employee does not intend to return from FMLA Leave or the date the Participant fails to return from FMLA Leave when such leave is exhausted.

         b) The date the Participant’s employment would have terminated and coverage would have been lost if the Employee had not taken FMLA Leave as the result of lay-off or the downsizing of the University.

         c) The date the Participant fails to make a required premium payment, if any, within the later of 30 days of the date due or 15 days after the University notifies the Participant that coverage will end for failure to pay required premiums.
             Coverage with respect to a Participant for whom a required premium payment has not been made shall cease as of the last day of the period for which the last contribution was made.

         2) A “key Employee”, as defined in 29 CFR Section 825.217, who does not return from FMLA Leave when notified of the University’s intent to deny reinstatement to employment shall be entitled to have coverage maintained unless and until the earlier of the following occur:

         a) The date the Employee notifies the University that said Employee does not desire to return to Active Work.

         b) The date the Employee is denied reinstatement after the conclusion of the FMLA leave.

      2. Continuation of Coverage under the Uniformed Services Employment and Reemployment Rights Act of 1994.

         1) A Participant who is on a leave protected by the Uniformed Services Employment and Reemployment Rights Act of 1994 (Military Leave) may choose to maintain coverage, and the coverage of Dependents covered by the Plan on the day immediately prior to such leave for the duration of Military Leave at the level and under the conditions that such coverage would have been provided if the Employee had continued Active Work.
             The Participant’s right to maintain such coverage shall end on the earliest of the following to occur:

         a) The date the Participant terminates employment by either notifying the University that the Employee does not intend to return from Military Leave or by failing to return from Military Leave within the time specified by law for protecting rights under the Act.

         b) The last day of the 18-month period beginning on the first day of Military Leave.

         c) Any other date permitted by law.

         2) Continuation of coverage under this Section shall run concurrently with the continuation of coverage provided in Section 500.010.J.2., and shall be credited towards satisfaction of the maximum coverage periods specified in that Section, to the extent permitted by law.

      3. Premium Amount

         1) Any premium paid by the Participant while on FMLA Leave shall be at the rate which the Participant would pay if the Employee had remained at Active Work with no additional charge for administrative expenses.

         2) A Participant on Military Leave that does not exceed 30 days shall pay a premium at the same rate that the Participant would pay if the Participant had remained at Active full-time work with no additional charge for administrative expenses. A Participant on Military Leave that exceeds 30 days is responsible for paying all Continuation Premiums for such coverage.

      4. Recovery of University Contributions for Providing FMLA Coverage

         1) To the extent permitted by law, the University may recover its share of the cost of providing coverage under the Plan paid during a period of unpaid FMLA Leave from a Participant if the Participant fails to return to Active Work after the Participant’s FMLA Leave entitlement has been exhausted or expires, unless the Participant’s failure to return is due to either:

         a) The continuation, recurrence, or onset of a serious health condition which would entitle the Participant to leave under FMLA.

         b) Other circumstances beyond the Participant’s control.
             Or the Participant is a “key Employee” who has been denied restoration as permitted under the Family and Medical Leave Act of 1993. The University may require medical certification of the serious health condition that precludes the Participant from returning to Active Work. Such certification must be provided within 30 days from the date of the University’s request.
            An Employee will be considered to have “returned to work” for purposes of this Section only if the Employee works at least 30 calendar days after the conclusion of the FMLA Leave. A Participant who transfers directly from taking FMLA leave to retirement, or who retires during the first 30 days after returning to Active Work shall be deemed to have returned to Active Work for purposes of this Section.

         2) The amount that the University may recover above is limited to an amount equal to the Continuation Premiums that would otherwise apply to such coverage, excluding any additional fee for administrative costs.

         3) The University may also recover the Participant’s share of any cost of continuing coverage for any FMLA Leave period during which the University maintains health coverage by paying the Participant’s cost of coverage after the Participant fails to make a required contribution.

       
9. General Provisions
   1. Control of This Plan
      1. The Plan may be changed or ended by the University without the consent of or notice to any person claiming rights or Benefits under this Plan. No change to end coverage shall affect any right to receive Benefits is such right existed before the date of the change or the date coverage ended. Any such right shall be subject to the terms and conditions of this Plan as they were prior to such date.
   2. Clerical Error
      1. Clerical error by the University shall not make the coverage of an ineligible person nor continue coverage which was ended by valid means. Neither the passage of time nor the payment of contributions by a person who is not eligible for coverage under the terms of this Plan will make this coverage valid for such person. If it is found that such a person was included when the contributions were figured for this Plan, the only liability of the University shall be the proper refund of contributions. Also, when a person is no longer eligible for coverage under this Plan, the payment of contributions by such person shall not continue coverage past the date such person ceases to be eligible. Again, the only liability of the University shall be the proper refund of premiums.
      2. Also, if any covered individual is listed in the wrong Benefit class or for an incorrect amount of coverage, the University shall have the right to correct such error at any time. The University shall pay only the amount of Benefits which are actually due under the covered individual's correct class. An appropriate adjustment of contributions will be made.
   3. Sex and Number -- When used in this Plan, the masculine includes the feminine, the singular the plural, and the plural the singular.
   4. Assignability of Coverage -- An Employee may not assign the rights to their Employee's coverage under this Plan.
   5. Misstatement of Age -- If the age of a covered individual has been misstated, any amounts payable will be adjusted in accordance with the individual's correct age. Any such misstatement shall neither continue coverage ended by valid means or void coverage otherwise valid and in force.
   6. Notice and Proof of Claim
      1. Written notice of a dental coverage claim must be given at least 45 days before the end of the calendar year which follows the calendar year in which the claim is incurred. However, in the event that dental coverage ends, notice of claim in writing must be given no later than 12 months after such claim was incurred. Written notice of any claim must be given to the University within 20 days after the date the loss on which claim is based occurs or commences. Notice should include the name of the covered individual and the number.
      2. Loss, as used in this provision, means covered expenses incurred.
      3. When the University receives the notice of claim, it will send the claimant forms for filing proof of claim. If these forms are not given to the claimant within 15 days, the claimant will meet the proof of claim requirement by giving the University a statement in writing of the nature and extent of the loss within the time limit stated in the paragraph below.
      4. Positive proof of claim must be given to the University before the end of the calendar year which follows the calendar year in which the loss is incurred. However, in the event that coverage ends, proof of claim must be given no later than 12 months after such loss is incurred.
      5. Proper positive written notice and proof of loss must be given before the University will be liable for any loss.
      6. If it was not reasonably possible to give notice and proof in writing in the time required, the University shall not reduce or deny the claim for this reason if proof is filed as soon as reasonably possible.
   7. Payment of Claim
      1. All Benefits that have not been validly assigned will be paid to the Employee.
      2. Claims for Benefits shall be paid as soon as due proof of claim is received.
   8. Facility of Payment
      1. All Benefits shall be paid as stated in the Payment of Claim Section except that Benefits not validly assigned will be paid as follows if:

         1) The Employee dies, the University may pay any unpaid Benefits to:

         a) The Employee's Spouse, if living;

         b) The Employee's living Children if such Spouse is not living;

         c) If no Children are living, to either the Employee's father or mother or to both equally if both survive;

         d) The Employee's estate if there is no Surviving Spouse, Children, or parents.

         2) Any payee, in the opinion of the University if not able to give a valid receipt and discharge for any payment, and claim is not made by duly appointed guardian or committee, the University, may, at this option, during the payee's lifetime, unless claim has been made by a duly appointed guardian or committee, pay any amount otherwise payable to the payee to any person or institution who, in the opinion of the University, is or has been:

         a) Rendering service to,

         b) Caring for, or

         c) Supporting such payee.

         3) The University may pay all or any Benefits for covered expenses to an institution or person providing dental care or supplies.

         4) Any payments made according to the above paragraphs will discharge the University to the extent of any such payment. The University shall not be bound to see to the use of the money so paid.

   9. Physical Examination -- The University, at its own expense, has the right to examine the person with respect to whom Benefits are claimed as often as reasonably needed while claim is pending.
      1. Not Workers' Compensation Insurance -- The coverage provided by this Plan will not take the place of and will not affect any requirement for coverage by Workers' Compensation Insurance nor does it pay in addition to Workers' Compensation.
      2. Assignment of Benefits and Claims and Creditors

         1) The Employee may assign the Benefits under this Plan only to such place or person rendering services or furnishing supplies for which Benefits are payable. The University shall not be responsible for the validity of any such assignment. Any payment made according to such assignment and in good faith by the University will discharge the University to the extent of any such payment.

         2) To the extent permitted by law, neither the Benefit nor payments under this Plan will be subject to the Claim of Creditors or to any legal process.

   10. Denial of Claim -- If a claim is wholly or partially denied, the Claims Service Contractor shall furnish the claimant with a written explanation of the denial within ninety days after receipt of the written proof of claim. If special circumstances exist which require an extension of time for processing the claim, the Claim Service Contractor shall have one hundred eighty days after receipt of the written proof of claim to furnish the claimant with a written explanation of its denial provided the Claims Service Contractor gives the claimant written notice of the special circumstances within ninety days of receipt of the written proof of claim. If the Claims Service Contractor fails to pay Benefits or furnish a written explanation of claim denial within such period, the claim shall be deemed denied for the purpose of the review procedure.
   11. Explanation of Denial -- The written explanation of a claim denial shall set forth, in a manner calculated to be understood by the claimant, the following information:
       1. the specific reason or reasons for the denial;
       2. specific reference to pertinent Plan provisions, if any, on which the claim denial is based;
       3. if the claim is denied because the Claims Service Contractor needs more information to make a decision, a description of any additional information necessary for the claimant to perfect the claim and explanation of why such information is necessary;
       4. a statement that the claim and its denial shall be reviewed upon submission of a written request to the Plan Administrator;
       5. a statement that the claimant, the claimant’s attorney, or other duly authorized representative shall have, as part of the review procedure, a reasonable opportunity:

          1) to examine pertinent Plan documents and records,

          2) to submit written comments on the issues; and

          3) a statement that the failure to submit a written request for review within sixty days after the receipt of the written explanation of the claim denial shall make the Claims Service Contractor’s decision final.

   12. Review Procedure -- A claim and its denial shall be reviewed by the Plan Administrator if a written request for review is filed within sixty days after receipt of the written explanation of the claim denial by the claimant. Otherwise, the initial decision of the Claims Service Contractor shall be the final decision of the Plan. As part of the review procedure, the claimant or the claimant’s duly authorized representative shall have a reasonable opportunity to examine pertinent Plan documents and records and to submit written comments on the issues.
   13. Decision on Review -- The Plan Administrator shall review the information and comments submitted by the claimant or the claimant’s duly authorized representative. The Plan Administrator shall furnish the claimant with a written explanation of decision or review within sixty days after receipt of a written request for review. If special circumstances exist which require an extension of time for reviewing the information, the Plan Administrator shall have one hundred twenty days after receipt of the written request for review to furnish the claimant with a written decision or review denial provided the Plan Administrator gives the claimant written notice of the special circumstances within sixty days of receipt of the written request for review. If the Plan Administrator fails to furnish a written explanation of decision on review within such time, the claim shall be deemed denied for the purposes of the review procedure.
   14. Explanation of Decision on Review -- The written explanation of the decision on review shall set forth, in a manner calculated to be understood by the claimant, the following information:
       1. the specific reason or reasons for the decision, including a response to the information and comments, if any, submitted by the claimant and the duly authorized representative; and
       2. specific reference to pertinent Plan provisions and records, if any, on which the decision is based.
   15. Limitation
       1. No action at law or in equity can be brought to recover on this Plan prior to the expiration of ninety days after written proof of claim has been furnished to the Claims Service Contractor.
       2. No action at law or in equity can be brought to recover after the expiration of three years after the time written proof of claim is required to be furnished to the Plan Administrator.
   16. Final Decision -- The decision of the Plan Administrator shall be final, comprehensive and legally binding for any and all purposes on all persons and shall not be subject to review.
        
10. Funding and Contributions
    1. Funding -- All of the costs of the Plan, including Plan Benefits and Plan administrative expenses, shall be paid out of funds received from the University equal to the:
       1. Contributions of Employees and Retired Employees pursuant to enrollment requirements; and
       2. University contributions.
    2. Contributions -- General -- Contributions hereunder are payable monthly to the University. The payment of any Contribution shall not maintain participation beyond the date on which the next Contribution becomes payable.
           Employees on leave of absence without salary are required to make their Employee Contributions by cash payments during their leave. The completed enrollment card is the authorization to the University to deduct the monthly Contributions from the salary or retirement Benefits of the Employee, Retired Employee or Surviving Spouse.
          Contributions are not prorated for a partial month.
          Monthly Contributions for participation effective after the first day of the month become due from the first day of the month next following the effective date of participation.
          Monthly Contributions for participation which terminates on the first day of the month or during the month shall cease at the end of the month in which participation was terminated.
    3. Contributions -- Basis for Determination
       1. Employees and Dependents -- For Employees enrolled in these programs, the Employee contribution will be one-half (1/2) of the amount required for participation in the program. The University will contribute the remaining one-half (1/2) of the required total contribution. This ratio will apply for coverage for the Employee as well as the covered Dependents of the Employee.
       2. Retired Employee and Dependents Contributions

          1) Retired Employees who retired prior to December 8, 1989 under the University of Missouri Retirement, Disability and Death Benefits Plan, or the Missouri State Employees Retirement System and Retired Employees who retired under the Civil Service Retirement System, regardless of the date of such retirement: For such Retired Employees and Dependents as described, the Retired Employee's contribution will be the same as determined for active Employees in accordance with Section 3.a. above.

          2) Surviving Spouse of an Employee, or retiree whose date of death was prior to December 8, 1989 the Surviving Spouse shall contribute the full amount required for participation in the program.

       3. Retired Employee who retires after December 7, 1989 under the University of Missouri Retirement, Disability and Death Benefits Plan, or the Missouri State Employees Retirement System, and Surviving Spouse of either an Employee or retiree as described herein whose date of death is on or after December 8, 1989:
              For such Retirees and Surviving Spouses and other Dependents, the University’s monthly contribution will be calculated based on the Percent of UM Maximum Premium Subsidy as described below.
             The University’s monthly contribution for Retired Employees and Surviving Spouses will be calculated on the following table:

For Spouses, Surviving Spouses and other covered Dependents of Retired Employees, the University subsidy will be one-half of the Percentage determined from the above table.

1) For active Employees who are vested in the University of Missouri Retirement Plan and who die on or after September 1, 1990, the University's monthly Contribution rate for eligible covered Dependents will be calculated as described above, as if the Employee had retired, rather than died.

2) Retired Employees Who Retired After December 6, 1991 and On or Before August 31, 1992: For Retired Employees who retired after December 6, 1991 and on or before August 31, 1992 under the University of Missouri Retirement Plan in accord with amendments to said Plan approved by the University's Board of Curators on December 6, 1991, the Age at Retirement or Years of UM Service Credit will be adjusted to the greater value calculated by using either (but not both) of the following:
  -- Age at Retirement increased to 65, or
  -- Years of UM Service Credit increased by 3.
  -- For Spouses and other covered Dependents or Retired Employees, the University subsidy will be one-half (2)of the percentage of the monthly Contribution paid by the University toward the Retired Employee's total premium Contribution rate.

3) Employees Who Die On or After September 1, 1990: For active Employees who are vested in the University of Missouri Retirement Plan and who die on or after September 1, 1990, the University's monthly Contribution rate for eligible covered Dependents will be calculated as described in Section (2), as if the Employee had retired, rather than died.

4) Retired Employees Who Retired On or After December 3, 1999 and on or Before September 1, 2000: For Retired Employees who retired after December 3, 1999 and on or before September 1, 2000 under the University of Missouri Retirement Plan in accord with amendments to said Plan approved by the University’s Board of Curators on December 6, 1991, the Age at Retirement or Years of UM Service Credit will be adjusted to the greater value calculated by using either (but not both) of the following:
  -- Age at Retirement increased to 65, or
  -- Years of UM Service Credit increased by 3.
  -- For Spouses and other covered Dependents of Retired Employees, the University subsidy will be one-half (1/2) of the percentage of the monthly Contribution paid by the University toward the Retired Employee’s total premium Contribution rate.

4. Maximum University contribution for coverage of Dependent Children -- Beginning September 1, 2001, the maximum number of Dependent Children upon which the University’s contribution will be based will be ten (10). Any Employee or Retired Employee who is enrolled for coverage of more than ten children will be required to pay the full additional cost for each such additional Child. In the event that an Employee is enrolled for coverage for more than ten children on September 1, 2001, the University contribution on behalf of such Employee’s Children will continue beyond that date with respect to those specific Children only. Any such Employee will be required to pay the full additional cost of any Child becoming covered on or after September 1, 2001 unless and until the total number of Children under such Employee’s enrollment equals ten or less.

 

11. Amendment and Termination of the Plan
    1. Right to Amend -- The University reserves the right to amend this Plan in whole or in part at any time. However, only The Curators of the University of Missouri, or any person expressly authorized by it to act for it with reference to matters expressly stated, is authorized to amend this Plan. Such amendment shall be binding upon all Employees, Retired Employees and Dependents (including those Participants on Continuation Coverage).
    2. Retroactive Amendments -- An amendment to this Plan may be made retroactively effective but will not adversely affect the rights of a Participant under this Plan for Covered Charges provided after the effective date of the amendment but before the amendment is adopted.
    3. Right to Terminate -- It is the intention of the University to continue the Plan indefinitely. However, the University reserves the right to modify or terminate the Plan in whole or in part at any time. However, only The Curators of the University of Missouri, or any person expressly authorized by it to act for it with reference to matters expressly stated, is authorized to terminate this Plan. Termination of the Plan shall apply to all Employees, Retired Employees and Dependents (including those Participants on Continuation Coverage).
        
12. Miscellaneous
    1. State Law -- This Plan shall be interpreted, construed and administered in accordance with applicable state or local laws to the extent such laws are not preempted by the laws of the United States.
    2. Status of Employment Relations -- The adoption and maintenance of this Plan shall not be deemed to constitute a contract between the University and the Employees or to be consideration for, or an inducement or condition of, the employment of an Employee. Nothing in this Plan shall be deemed:
       1. to affect the right of the University to discipline or discharge any Employee at any time;
       2. to affect the right of an Employee to terminate his employment at any time;
       3. to give the University the right to require any Employee to remain in its Employee; and
       4. to give any Employee the right to be retained in the Employee of the University.
    3. Word Usage -- Whenever words are used in this document in the singular or masculine form, they shall, where appropriate, be construed so as to include the plural, feminine, or neuter form.
    4. Titles are Reference Only -- The titles are for reference only. In the event of a conflict between a title and the content of a Section, the content of the Section shall control.
    5. Plan Year -- The Plan year shall be January 1 to December 31.
        
13. Trust Fund
    1. Trust Fund
       1. The fund upon the books of The Curators of the University of Missouri designated as Dental Benefit Plan and all additions thereto is hereby set aside and dedicated as a Trust Fund to be held by The Curators of the University of Missouri in trust so long as any Benefits payable under the Plan or any amendments adopted thereto prior to its termination may be outstanding and may become payable. Such Trust Fund shall be used solely for the purpose of payment of such Benefits and not be subject to diversion for any other purpose so long as said trust shall exist.
       2. All such money and such payments as shall from time to time be made to the fund in accordance with the Plan or by direction of the Board and such earnings, profits increments and accruals thereon as may occur from time to time and all money or property paid or delivered into the fund by State appropriation or by others and all investments made therewith or proceeds thereof and all earnings and profits thereon, less the payments which at time of reference shall have been made by the Trustee as authorized herein shall constitute the fund. The fund shall be held by The Curators of the University of Missouri as Trustee and dealt with solely in accordance with the expressed provisions of this Plan.
       3. The fund shall be the sole source of all medical Benefit payments or other Benefits provided under this Plan and in no circumstance shall nay other funds of the University, The Curators of the University of Missouri, any member of the Board individually, Employees of the University, or any individuals who are members thereof, be liable or responsible.
    2. Trustees
       1. It shall be the duty of the Trustee hereunder to hold, posses, manage and subject to the provisions of this Section hereof, to invest and to reinvest the fund and to pay monies from the fund as provided for in the Plan.
       2. The Trustee hereunder shall hold, possess, manage and control the property which from time to time constitutes the fund by it hereunder, with full power and authority as follows:

          1) To lease for any period, sell, exchange, transfer and convey any of the trust property, real or personal, upon such terms and in such manner and for such prices or consideration as to it shall seem fit and proper; and no person dealing with the Trustee shall be bound to see to the application of the purchase money or to inquire into the validity, expediency, or propriety of any such sale or other disposition;

          2) To invest and reinvest all and every part of the trust estate in such manner and in such real estate, such stocks, common or preferred, bonds, debentures, mortgage notes, shares or participation in common Trust Funds (including any common Trust Fund or other special pooled fund managed by the Trustee) or investment trusts and other property, either personal or real, as to the trustee shall seem desirable investments, having particularly in view the preservation of the trust estate and the amount and regularity of the income to be derived therefrom and such investments and reinvestment shall not be restricted to securities or property of the character required for investment by Trustees or for the investment of Trust Funds under any present or future laws;

          3) To retain without liability for depreciation or loss any and all property, real or personal, tangible or intangible, which is delivered to and received by the Trustee to be held by it pursuant to the terms hereof so long as the Trustee, in its discretion believes such property to be a desirable investment for this trust;

          4) In its absolute discretion, to keep such portion of the fund in cash or cash balances as it may deem advisable from time to time. Without limiting the generality of the foregoing, the Trustee shall keep such portion of the Fund in cash or cash balances as may be needed to meet contemplated Benefit payments;

          5) To commingle all or part of the property at any time constituting the fund with any other property held by it in trust or for its own account for the purpose of investing to better advantage the property held hereunder;

          6) To exercise all rights and privileges with relation to any securities at any time held as part of the fund, including, but not by way of limitation, the right to carry the same in the registered name of a nominee of the Trustee and to exercise conversion, subscription and voting rights and to grant proxies, discretionary or otherwise;

          7) To enforce any right, obligation, or claim in its absolute discretion, in general to protect in any way in the interests of the fund, either before or after default and where it shall consider such action for the best interest of the fund and in its absolute discretion to abstain from the enforcement of any right, obligation or claim;

          8) From time to time to Employee suitable agents, assistants and counsel and to pay their compensation from the fund and to pay from the fund all reasonable expenses incident to and arising out of the administration of the fund, provided, however, no money shall ever be paid from the fund to the Trustee as fees or compensation for any service rendered by it as Trustee in the control, management and administration of the trust;

          9) Notwithstanding any other provision hereof, to employ on behalf of the trust one or more banks, trust companies or other investment counsel as agent of the Trustee under an agency agreement providing that the bank, trust company, or other investment counsel shall hold and have sole custody of and invest such of the funds of the trust placed under its care within the terms and conditions of the agency agreement, which agency agreement shall conform to the limitations of this Plan. Under any such agency agreement, the Trustee may delegate to the bank, trust company or other investment counsel the power and responsibility for the selection, purchase and sale of securities for the trust and such other powers and responsibilities imposed upon the Trustee hereunder, whether ministerial or discretionary, as the Trustee deems advisable or necessary, subject at all times to the full control and direction of the Trustee and the duty exercise of all such powers and responsibilities as may be required by the Trustee;

          10) To execute all documents and papers and do and perform all acts which it may deem necessary or proper in the exercise of any and all of the powers of the Trustee provided hereunder upon such terms and conditions as to it may seem for the best interest of the fund.

       3. The Trustee shall not be liable for the making, retention, or sale of any investment or reinvestment made by it as herein provided or for any loss to or diminution of the fund, or for anything done or omitted to be done by it, except for its own negligence, willful misconduct or lack of good faith. The Trustee shall be fully protected in acting upon advice of competent counsel.
       4. As of June 30 of each year, the Trustee shall prepare a report of the status of the fund, which report shall be presented to the Board and filed with the minutes of the meeting at which the report is presented. Such reports always shall be subject to inspection by any interested person at any reasonable time. Each such report shall contain the following information:

          1) The present composition of the fund with notations of changes therein since the date of the last report;

          2) A description of all reinvestment made since the date of the last report;

          3) An extension of the fair market value as of the date of the report of each item held in the trust;

          4) A statement of the amount and source of income received since the date of the last report;

          5) A statement of the distributions from the fund since the date of the last report, giving the total amounts paid for medical Benefits payments, administrative fee payments and consulting fee payments.

          6) Such other data and information as the Board may from time to time reasonably require.

    3. Right to Amend Trust
       1. The Board may at any time and from time to time as otherwise provided in the Plan modify or amend, in whole or in part, any or all of the provisions of this trust, provided that no such modification or amendment shall divert the fund or any part thereof from the purposes for which it is dedicated. It shall be impossible by operation of this trust, by natural termination thereof, by power of revocation or amendment, by the happening of any contingency, by collateral arrangement, or by any other means for any part of the fund or the income therefrom to be used for or diverted to purposes other than for the exclusive Benefit of the members of the Plan.
       2. In the event any provision of this trust shall be held illegal or invalid for any reason, said illegality or invalidity shall not affect the remaining provisions of this trust, but shall be fully severable and the trust shall be construed and enforced as if said illegal or invalid provisions had never been inserted therein.
        
14. Privacy and Confidentiality of Health-Related Information
    1. Definitions -- The following definitions are in addition to those definitions set forth in Section 500.010(B):
       1. Plan Sponsor: The Curators of the University of Missouri
       2. Protected Health Information (“PHI”): individually identifiable health information as defined in 45 C.F.R. Section 164.501.
       3. Business Associate: a person or entity who performs services for the Plan involving the use or disclosure of individually identifiable health information, as defined in 45 C.F.R. Section 160.103.
    2. Plan Sponsor’s Certification of Compliance -- Neither the Plan nor any health insurance issuer or Business Associate servicing the Plan will disclose Plan Participants’ PHI to the Plan Sponsor unless the Plan Sponsor certifies that the Plan Documents have been amended to incorporate this Section and agrees to abide by this Amendment.
    3. Purpose of Disclosure to Plan Sponsor
       1. The Plan and any health insurance issuer or Business Associate servicing the Plan will disclose Plan Participants’ PHI to the Plan Sponsor only to permit the Plan Sponsor to carry out plan administration functions for the Plan not inconsistent with the requirements of the Health Insurance Portability and Accountability Act of 1996 and its implementing Regulations (45 C.F.R. Parts 160-164). Any disclosure to and use by the Plan Sponsor of Plan Participants’ PHI will be subject to and consistent with the provisions of this Section.
       2. Neither the Plan nor any health insurance issuer or Business Associate servicing the Plan will disclose Plan Participants’ PHI to the Plan Sponsor unless the disclosures are explained in the Notice of Privacy Practices distributed to Plan Participants by the Plan.
       3. Neither the Plan nor any health insurance issuer or Business Associate servicing the Plan will disclose Plan Participants’ PHI to the Plan Sponsor for the purpose of employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.
    4. Restrictions on Plan Sponsor’s Use and Disclosure of PHI
       1. The Plan Sponsor will neither use nor further disclose Plan Participants’ PHI, except as permitted or required by the Plan Documents, as amended, or required by law.
       2. The Plan Sponsor will ensure that any agent, including any subcontractor, to whom it provides Plan Participants’ PHI agrees to the restrictions and conditions of the Plan Documents, including this Section, with respect to Plan Participants’ PHI.
       3. The Plan Sponsor will not use or disclose Plan Participants’ PHI for employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.
       4. The Plan Sponsor will report to the Plan any use or disclosure of Plan Participants’ PHI that is inconsistent with the uses and disclosures allowed under this Section promptly upon learning of such inconsistent use or disclosure.
       5. The Plan Sponsor will make PHI available to the Plan Participant who is the subject of the information in accordance with 45 C.F.R. Section 164.524.
       6. The Plan Sponsor will make Plan Participants’ PHI available for amendment, and will on notice amend Plan Participants’ PHI, in accordance with 45 C.F.R. Section 164.526.
       7. The Plan Sponsor will track disclosures it may make of Plan Participants’ PHI so that it can make available the information required for the Plan to provide an accounting of disclosures in accordance with 45 C.F.R. Section 164.528.
       8. The Plan Sponsor will make available its internal practices, books and records, relating to its use and disclosure of Plan Participants’ PHI, to the Plan and to the U.S. Department of Health and Human Services to determine compliance with 45 C.F.R. Parts 160-164.
       9. The Plan Sponsor will, if feasible, return or destroy all Plan Participant PHI, in whatever form or medium, including any electronic medium under the Plan Sponsor’s custody or control, received from the Plan, including all copies of any data or compilations derived from and allowing identification of any Participant who is the subject of the PHI, when the Plan Participants’ PHI is not longer needed for the plan administration functions for which the disclosure was made. If it is not feasible to return or destroy all Plan Participant PHI, the Plan Sponsor will limit the use or disclosure of any Plan Participant PHI it cannot feasibly return or destroy to those purposes that make the return or destruction of the information infeasible.
    5. Adequate Separation Between the Plan Sponsor and the Plan
       1. The following classes of employees or other workforce members under the control of the Plan Sponsor may be given access to Plan Participants’ PHI received from the Plan or a health insurance issuer or business associate servicing the Plan:

          1) any employee who serves as the Plan Administrator;

          2) any employee who serves as a Plan fiduciary; and

          3) any employee who performs functions related to the Plan, including but not limited to human relations, audit, legal, accounting and systems personnel.
              This list includes every class of employees or other workforce members under the control of the Plan Sponsor who may receive Plan Participant’s PHI relating to payment under, health care operations of, or other matters pertaining to the Plan in the ordinary course of business.

       2. The classes of employees or other workforce members identified in paragraph 5(a) of this Section will have access to Plan Participants’ PHI only to perform the plan administration functions that the Plan Sponsor provides for the Plan.
       3. The classes of employees or other workforce members identified in paragraph 5(a) of this Section will be subject to the Plan Sponsor’s disciplinary policies and procedures up to and including termination of employment or affiliation with the Plan Sponsor, for any use or disclosure of Plan Participants’ PHI in breach or violation of or noncompliance with the provisions of this Section to the Plan Documents. Plan Sponsor will promptly report any such breach, violation or noncompliance to the Plan, as required by paragraph 4(d) of this Section, and will cooperate with the Plan to correct the breach, violation or noncompliance, to impose appropriate disciplinary action or sanctions on each employee or other workforce member causing the breach, violation or noncompliance, and to mitigate any deleterious effect of the breach, violation or noncompliance on any Plan Participant, the privacy of whose PHI may have been compromised by the breach, violation or noncompliance.
    6. Disclosure by Others to the Plan Sponsor -- The Plan Sponsor shall be entitled to receive PHI from:
       1. the Plan;
       2. any business associate of the Plan;
       3. any person or entity that contracts with such business associate;
       4. any person or entity that contracts with the Plan Sponsor to provide services to or on behalf of the Plan;
       5. any health insurer or health insurance issuer or HMO that provides health benefits coverage or services to or on behalf of the Plan;
       6. any health care clearinghouse that provides services to or on behalf of the Plan or with respect to Plan participants; and
       7. any other person or entity that maintains, or has the authority to direct the disclosure of, PHI related to any Plan Participant.
    7. Permitted and Required Uses and Disclosures of PHI
       1. Permitted Uses and Disclosures. The Plan Sponsor is and shall be entitled to use and disclose any PHI obtained pursuant to the authority set forth in this Plan Document, and any other information that may reasonably be deemed to be PHI, regardless of the source of such information, that comes into the possession of the Plan Sponsor, only for the following purposes:

          1) to provide and conduct administrative functions related to payment and health care operations for an on behalf of the Plan;

          2) to audit payments for claims incurred under the Plan;

          3) to request proposals for services to be provided to or on behalf of the Plan; and

          4) to investigate fraud or other unlawful act related to the Plan and committed or reasonably suspected to have been committed by the Plan Participant.

       2. Required Uses and Disclosures of PHI: The Plan Sponsor shall be required to use and/or disclose PHI:

          1) to an individual, when requested under, and required by 45 C.F.R. Section 164.524, in order to provide an individual with access to his or her own PHI;

          2) to an individual, when requested under, and required by 45 C.F.R. Section 164.528, in order to provide an individual with an accounting of disclosures of that individual’s PHI; and

          3) when required by the Secretary of the Department of Health and Human Services or those acting under the authority or at the direction of the Secretary to investigate or determine the Plan’s compliance with the Privacy Regulations.

    8. Prohibited Uses and Disclosures of PHI -- The Plan Sponsor shall not be entitled to use or disclose PHI for any purpose for which use and disclosure is not expressly allowed under this Plan Document, including but not limited to:
       1. using or disclosing PHI other than as permitted or required under this document or applicable law, or in a manner inconsistent with the Privacy Regulations; and
       2. taking adverse employment action against any Plan Participant who is an employee of Plan Sponsor, except with respect to any fraud or unlawful act related to the Plan and committed or reasonably suspected to have been committed by such person.
    9. Minimum Necessary -- When using or disclosing PHI or when requesting PHI from another party, the Plan Sponsor must make reasonable efforts to limit PHI to the minimum necessary to accomplish the intended purpose of the Use or disclosure, and limit any request for PHI to the minimum necessary to satisfy the purpose of the request.
           The University of Missouri Medical Benefits Plan and the University of Missouri Dental Benefits Plan, by virtue of their common sponsorship and control by The Curators of the University of Missouri, are deemed affiliated covered entities for purposes of compliance with the final HIPAA Privacy Rule.
     

Appendix to the Dental Plan Document

Schedule of Benefits

1. A Calendar Year Deductible of $100 per Participant is applicable to Type B Dental Expenses and Type C Dental Expenses only. No deductible applies to Type A Dental Expenses. The Calendar Year Deductible is applicable to Type B Dental Expenses and Type C Dental Expenses combined.
2. A Family Deductible Limit of $300 will be applicable if the participants of one family (consisting of the Employee and dependents covered by the Program) incur Type B and Type C Covered Dental Expenses, collectively, that are applied toward the Calendar Year Deductible in any Calendar Year. No further Calendar Year Deductibles will subsequently be required for any participants in that family unit for the remainder of the Calendar Year.
3. After the applicable Calendar Year Deductible, the Benefits Payable for Covered Dental Expenses as described below:
   1. Type A Dental Expenses are payable at 100%, and are not subject to a Calendar Year Deductible.
   2. Type B Dental Expenses in excess of the Calendar Year Deductible are payable at 80%.
   3. Type C Dental Expenses in excess of the Calendar Year Deductible are payable at 50%.
4. A Dental Maximum of $1,500 per calendar year will be applicable to Benefits payable under this Plan for each Participant.