f/k/a  Level Dental, Vision and Medical Benefit Terms

These terms (the “ERISA Benefit Plan Terms”) are agreed by Level Benefits, Inc., a Delaware corporation doing business as Level and Level Administrators (together with its affiliates, “Level”) and the organization purchasing third party administrator services from Level (“Sponsor,” and together with Level, the “Parties”). These Terms govern the engagement of Level by Sponsor to provide services (“Services”) to individuals enrolled (“Participants”) in plan governed by the Employee Retirement Income Security Act of 1974, as amended from time to time (the “Plan”), that Sponsor will offer to its eligible employees and their eligible dependents. By purchasing the Services from Level, Sponsor agrees to the Level Customer Terms (the “Customer Terms” available at level.com/legal/terms), these Benefit Plan Terms, and all other applicable terms listed at level.com/legal/terms or incorporated by reference herein (together, the “Terms”).

1. Level’s Services

Subject to the rights and obligations under the Terms, Level will provide the following Services, as well as those Services set forth in the Customer Terms.

Identification Cards. Level will prepare and issue digital identification cards for Sponsor’s Participants, which include the Participant’s Member ID and may include Level’s name and logo. 

Network Services. Level will provide Participants with access to Level’s network of contracted dentists and other providers as applicable based on the products purchased by Sponsor (“Participating Providers”). Level does not guarantee the availability of any provider and Level does not guarantee that any particular provider will provide any particular service.

1. Payment to Participating Providers. Level will reimburse Participating Providers for services rendered to Participants in accordance with Level’s agreements with Participating Providers and the terms of the Plan. Level will have no obligation to reimburse Participating Providers if Sponsor does not provide requisite funding to Level.
2. Billing by Participating Providers. Participating Providers agree to accept Level’s allowable amount along with applicable deductibles, copayments, and other member cost-sharing as payment in full for covered services rendered to Participants. Participating Providers may bill Participants for copayments and coinsurance (as applicable) for covered services, and for the amount of any uncovered services, but will not otherwise bill Participants.  Participating Providers may also charge a Participant’s Level Card.
3. Provider Directory. Level will provide Participants access to an online directory of Participating Providers (“Provider Directory”). Upon request by Sponsor, Level will provide a printable version of the Provider Directory to Sponsor.
4. Communication with Participating Providers. Level will be solely responsible for acting as a liaison with Participating Providers including, but not limited to, responding to provider inquiries and complaints, unless the source of inquiry or complaint is solely related to Sponsor’s action or inaction.‍
5. Participating Provider Status. Level does not employ Participating Providers. Participating Providers are independent contractors and are solely responsible for exercising professional judgment related to a Participant’s care.

Claims Services. Level will accept in-network and out-of-network claims for benefits. In-network claims will be submitted directly to Level by the Participating Providers. Out-of-network claims may be submitted directly to Level by the provider or the Participant. If an out-of-network provider requires immediate payment in full by the Participant, then to obtain benefits for an out-of-network claim, the Participant must submit the claim to Level or use their Level Card (if applicable).

1. Claims Processing. Level will determine the amount of benefits payable for each claim, notify the Participant of its decision concerning the claim; and disburse payments to the provider or the Participant, as applicable. If the Participant is an unemancipated minor, or not competent to handle funds (as determined by Level in its sole discretion), Level will provide payment to the Participant’s parent or legal guardian who is an employee of Sponsor, or to another appropriate person as determined by Level in its sole discretion.
2. Basis of Determinations. Level will determine and review claims for benefits, in accordance with the terms of the Plan (as detailed in the Benefit Booklet) and the directions issued by Sponsor, if applicable.
3. Claims Review. Upon request by the relevant Participant or Sponsor, Level will review requested denied claims. Level will notify the Participant or Sponsor of its decision upon completion of the review.  Unless otherwise prohibited by law, Sponsor may direct Level, on an exceptions basis, to process and pay claims denied by Level or to otherwise act in a manner inconsistent with the Benefit Booklet by written direction from Sponsor’s authorized representative. All charges will be additional to, and outside of, the Plan.  Level will not be responsible for any liability associated with any act or omission undertaken at Sponsor’s direction under this provision.
4. Compliance. In providing the Claims Services described above, Level will comply with the Benefit Booklet and 29 C.F.R. § 2560.503-1.‍
5. Notice of Legal Action. If Level receives notice of any legal action that concerns a claim for Plan benefits and names Level, Sponsor, or the Plan as a party, Level will promptly notify Sponsor.

Documentation Services. Level will provide drafts of the following documents for the Plan, subject to review and revision by Sponsor: a booklet that summarizes the benefits and to whom those benefits are payable (the “Benefit Booklet”) and a one page benefit summary. Level may also provide a summary plan description (“SPD”) either in template or draft form based solely on information provided by Sponsor. In each case, Sponsor will be solely responsible for determining the final text of the relevant document and ensuring that it meets applicable legal requirements; however, Level also reserves the right to revise such documents to comply with a change in applicable law. Level will make the Benefit Booklet, Benefit Summary, and, where requested, the SPD, available to Participants through Level’s website, mobile application, email, or otherwise.  Level will not be responsible for printing or distributing a paper version of the documents.

Catastrophic Event. If a catastrophic event, whether weather-related, caused by a natural disaster, or caused by war, terrorism, or similar event, occurs that affects Participants in one or more locations, and such catastrophic event prevents or interferes with Level’s ability to conduct its normal business with respect to such Participants or prevents or interferes with Participants’ ability to access their benefits, Level will have the right, without first seeking consent from Sponsor, to take reasonable and necessary steps to process claims and provide services in a manner that may be inconsistent with the Benefit Booklet in order to minimize the effect such catastrophic event has on Participants. As soon as practicable after a catastrophic event, Level will report its actions to Sponsor. Sponsor will reimburse Level for amounts paid in good faith under the circumstances, even if the charges incurred were not for services otherwise covered under the Benefit Booklet.

2. Sponsor’s Responsibilities and Obligations

Plan Design. Sponsor will provide Level with ninety (90) days’ written notice prior to any change in the eligibility rules, the covered benefits and/or the Plan documents.

Eligibility. Sponsor will be solely responsible for determining which individuals are eligible and enrolled, and for determining which Participants have become ineligible and must be disenrolled. Sponsor agrees to provide Level with all such necessary eligibility information. Sponsor will provide Level with changes in eligibility as soon as practical in the month in which the change occurs.

Payment by Sponsor.

1. Claims Responsibility. Level does not assume any financial risk or obligation with respect to claims. Sponsor agrees to fund all benefits Level approves during the Term of the Terms. Sponsor is solely responsible for providing funds for payment of all approved claims for benefits. Level does not assume any financial risk or obligation with respect to claims. If claims are paid for a Participant who is later determined to have been ineligible, and if the claims payment is a result of Sponsor providing inaccurate information to Level (e.g., incorrectly advising Level that the individual was eligible and enrolled, or failing to notify Level that the Participant had become ineligible), Sponsor will be financially responsible for such claims.
2. Fees. Sponsor will pay Level an administrative service charge, including any applicable broker fees (“Service Charge”).
3. Changes. At any time during the Term, Level reserves the right to update amounts owed for the Services if Customer’s enrollment changes more than 10% from the beginning of the relevant Service Term.

Employee Communications. Sponsor will use reasonable efforts to provide Level with advance copies of all employee communications regarding the Plan, if any, so that Level’s customer service representatives can respond appropriately to inquiries that may result.

Reimbursement Requests. If Medicare, Medicaid, the Veterans Administration, or any other federal or state entity asserts a reimbursement right against Sponsor, the Plan, or Level with respect to claims processed by Level under the Terms, Sponsor will be responsible for paying and/or reimbursing Level for any such amounts determined to be owed.

Continuation Coverage. Sponsor will be solely responsible for determining whether an individual is eligible for and has enrolled in continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”). Sponsor is solely responsible for compliance with the provisions of COBRA, including but not limited to all COBRA notice obligations. 

HIPAA. The Services are subject to Level's Business Associate Agreement (available at level.com/legal/baa). If Sponsor requests Protected Health Information from Level (other than enrollment and disenrollment information, “summary health information” as defined by HIPAA, or information pursuant to an individual’s authorization), Sponsor’s request will constitute a representation that the Plan document contains language consistent with 45 C.F.R. § 164.504(f), allowing Sponsor to receive such PHI, and that Sponsor has provided the Plan with a certification in accordance with 45 C.F.R. § 164.504(f)(2)(ii).

3. ERISA

Sponsor’s Status. Sponsor is the “Plan Sponsor,” “Plan Administrator,” and Named Fiduciary, as those terms are defined by the Employee Retirement Income Security Act of 1974, as amended (“ERISA”). Sponsor may name another entity or individual as Plan Administrator, provided that such Plan Administrator is not Level or a Level employee. Sponsor retains all authority and responsibility for the Plan and its operations.

Delegation. Sponsor hereby delegates to Level the authority to decide claims and appeals, in accordance with the Terms. 

Level’s Status. The Parties acknowledge that Level will be a fiduciary, as defined by ERISA, with respect to the appeal of any denied claims. The Parties acknowledge and agree that Level will not be a fiduciary for any other purpose under the Terms.

4. Run-Out Services

Unless requested otherwise by Sponsor, Level will continue the claim processing services for six (6) months following the date of termination (“Run-Out Period”). During the Run-Out Period, Level will complete the processing of all claims in Level’s possession on the date of termination, and any claims incurred prior to the date of termination and received during the Run-out Period, and make benefit payments (collectively, the “Run-Out Services”). Level’s obligation to provide Run-Out Services is subject to and contingent upon Sponsor’s timely funding of Plan benefits. During the Claims Run-out Period, the relevant terms of the Terms will continue to apply. Level will have no obligation to process or pay any claims or forward claims to Sponsor beyond the Claims Run-out Period. During the Run-Out Period, Sponsor will not be obligated to pay Service Charges but will instead pay a Run-Out Fee to Level prior to the termination of the Terms. The Run-Out Payment will be equal to one month's Service Charge, plus anticipated claims amounts as determined by Level.

5. State-Specific Terms 

To the extent required by applicable law or regulation, Level will comply with the additional terms set out below, and may comply with additional applicable state laws if required.  

Michigan. In accordance with Michigan statute MCL 550.932(1), Level will provide to each Participant living in Michigan who is covered by a plan administered by Level written notice of the following: what benefits are being provided to the Participant; changes in the Participant’s benefits; the fact that Participants covered by the plan are not insured or are only partially insured, as the case may be; if the Participant's plan is not insured, the fact that in the event the plan or the Sponsor does not ultimately pay medical expenses that are eligible for payment under the plan for any reason, the Participants covered by the plan may be liable for those expenses; the fact that Level merely processes claims and does not insure that any medical expenses of individuals covered by the plan will be paid; the fact that complete and proper claims for benefits made by Participants covered by the plan will be promptly processed but that in the event there are delays in processing claims, the Participants covered by the plan will have no greater rights to interest or other remedies against Level than as otherwise afforded them by law.

New Jersey. For each Participant living in New Jersey, Level will comply with N.J.A.C 11:23-3.1(c)3 by:

1. maintaining appropriate backup systems against the loss of records, including but not limited to, appropriate data retention configurations with cloud services used, system backups either daily or else as necessary, and disaster recovery and business continuity policies and procedures;
2. maintaining and establishing appropriate financial controls, including but not limited to, third party audits of internal practices; maintaining books, and records relating to payments received and sent; and making these controls and records available upon request;
3. allowing Participants in New Jersey the right to claims audits by a third party auditor; and
4. maintaining appropriate insurance coverage, which will include general liability insurance, valuable papers insurance and errors and omissions coverage and such other coverage as appropriate.

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Last updated: December 20, 2024