TACT : More than a Health Plan

TACT DENTAL PLAN

Texas Ag Coop Trust
Direct Reimbursement Dental Care Benefits

Effective January 1, 2008

Good dental care is important to your health and your appearance! For that reason, your employer and TACT have made available the dental plan described below:

The Plan
• Allows you to use the dentist of your choice and to obtain the service you and your dentist agree upon.
• Has no waiting periods before certain procedures are covered.
• Have no excluded procedures except cosmetic procedures as required by IRC 213.
• Has no requirement for pre-approval of the procedure.
• Has no maximum fee schedule for each procedure. The dentist’s normal fees are allowable expenses.
• Allows orthodontic care to be covered the same as any other procedure. (Commencement of orthodontic treatment begins the date the braces are placed on the teeth. Orthodontists typically require a down payment and collect the balance of their fees over the duration of the treatment. For claims ¼ (25%) of the entire treatment plan charge will be reimbursed under the benefit formula. The balance of the charges ¾ (75%) will be reimbursed monthly by the plan over the period of treatment. Benefit checks will be sent monthly until the treatment plan is finished or coverage terminates.

How The Plan Works
Every year beginning January 1st, you and your covered dependents each have $2,000 coverage for dental care. The plan reimburses you:

• 0% of the first $50 of eligible dental expenses, then
• 100% of the next $100 of eligible expenses, then
• 80% of the next $500 of eligible expenses, then
• 50% of the next $3,000 of eligible expenses to
a maximum benefit of $2,000 per year.

Monthly Cost	Total Cost	Your Share
Employee Coverage:	$ 22.90	$_______
Employee + Spouse Coverage:	$ 46.40	$_______
Employee + Children Coverage:	$ 52.50	$_______
Employee + Spouse & Children Coverage:	$ 68.38	$_______

How Direct Reimbursement is Used and How Reimbursements are Made:
1. The patient selects a dentist and agrees to a treatment plan.
2. The dentist mails an ADA claim form to Total Administrative Services Corporation“TASC”for payment.
3. The benefit check is mailed to the employee or to the dentist, if there is an assignment of benefits, within 10 days (including mail time).

To Enroll
Complete the dental enrollment form and return it to TACT. Your coverage election is irrevocable and will continue for the plan year unless there is a significant family status change, such as a marriage, divorce, death, birth or change in the employment status of your spouse.

Filing for Reimbursement
ADA claim forms should be mailed to:
Total Administrative Services Corp. (TASC)
2302 International Lane
Madison, WI 53704-3140
Fax : 608-663-2754
For claims service call: 1-800-422-4661