Page 167 - Washington Nationals 2023 Benefits Guide -10.26.22_Neat

APPENDIX C

WASHINGTON NATIONALS BASEBALL CLUB LLC DENTAL PLAN

Name of Club/Baseball-Related Entity: Washington Nationals Baseball Club, LLC

Eligible Employees: All active employees working a minimum of 35 hours per week (“Full-Time
Employees”)

Eligible Dependents:

• spouses;
• children (including your biological children, adopted children, foster children, or step-
children) until the end of the calendar year in which the child turns age 26; and
• unmarried disabled dependent children age 26 and older.

Employee Contributions: You are required to contribute towards the cost of the coverage you
elect at the rates established each year by your Employer.

Insurance Effective Date: January 1, 2017

New Hire Effective Date: Coverage will become effective on the first day of the month
coinciding with, or next following, your date of hire; provided that you are an Eligible Employee
on that date. For the avoidance of doubt, coverage will become effective on the date of hire if an
Eligible Employee is hired on the first day of the month.

Date Coverage Terminates: Last day of the month in which termination (or loss of eligibility)
occurs.

Dental Option Offered: Concordia Flex

This program generally pays 100% of costs up to the maximum allowable charge for Class I
Services, 80% of costs up to the maximum allowable charge for Class II Services (except general
anesthesia), and 50% of the costs up to the maximum allowable charge for Class III Services and
Orthodontics. Class II and Class III services are covered after a $50 per member deductible (not
to exceed $150 per family). Class I, II and III Services and Orthodontics are subject to a $1,500
annual maximum per person, and there is a separate $1,000 lifetime maximum per person for
Orthodontics. Orthodontics are also limited to dependent children under age 19.

Participating dentists accept the maximum allowable charge as payment in full. This means that
if an out-of-network dentist performs a covered service, you will be responsible for paying the
deductible, any part of the maximum allowable charge that is not covered, and any amount charged
by the out-of-network dentist in excess of the maximum allowable charge. Please refer to the
benefits booklet for more information.

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