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Download 600S Enrollment Form - DAIS - Dental Alternatives Insurance
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Dental HMO SmileSaver Individual 600S Enrollment Kit This plan will provide you with excellent dental benefits and save you money. You know how important it is to maintain good oral health and this plan helps with low or no co-payments for preventive services. But there is more than just preventive care … restorative treatment is also covered at co-payments considerably lower than what you might expect to pay without this plan. About this plan … • No waiting periods, claims forms, deductibles or maximums • You will access care through a network of pre-screened general dentists. You and each enrolled dependent may select a different network dentist. • Emergency care is available (see Evidence of Coverage within this booklet). • Specialty care is covered; review the enclosed Schedule of Benefits to find out more. SmileSaver dental and vision plans are provided by SafeGuard Health Plans, Inc. SafeGuard has been a leader in the dental benefits industry for 30 years. Our continued success is due to excellent service, quality products and the fact that, at SafeGuard, our members are our first priority. Member satisfaction is monitored to ensure we meet our goals and your expectations. This booklet contains important information about your benefit plan – including your Schedule of Benefits and Evidence of Coverage. You will receive an ID card after your enrollment has been processed; in the meantime, you may use the temporary card below. Temporary Identification Card PRINT NAME SIGNATURE This card is not required to obtain services SafeGuard Network Dentists SafeGuard contracts with dentists who meet our high quality standards, ensuring you the best dental care available. Each dentist is pre-screened and each office is thoroughly evaluated prior to being accepted into our network. Online Directory Instructions Before you enroll... x Select a general dentist from the Directory of SafeGuard Participating Dentists x You and each of your enrolled dependents may select different general dentists Online Dentist Listing The most current network information can be found in our online directory at www.safeguard.net. x x x Click on “Dental & Vision Directories” Choose "Visitor" and then select “Dental HMO” and state. Select your plan from the scroll down menu (check the Schedule of Benefits in this booklet for the name of your plan). You will be able to search by city, county, zip code, or by a particular dentist's name. After enrollment... To access the directory once you are enrolled, log in to our website and use your Family ID number, Group ID number, or social security number (Family and Group ID numbers are provided on your ID card). If you have any questions, you can call Customer Service at 800.880.1800 or log on to our website at www.safeguard.net/contact.html to email us your questions. SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* SmileSaver 600 South Principal Benefits and Coverages: The following services are the principal benefits to which Members are entitled. Only these procedures are provided for, either partially or totally by the Plan. The Member may be responsible for a co-payment for these procedures. Please reference your Evidence of Coverage to fully understand what is meant by Coverage for a given procedure. If a service is requested and provided to a Member and the procedure is not listed in this Schedule of Benefits, the Member shall pay the dentist his or her usual and customary fee for the treatment received. There may be some procedures that are listed in this document that may not be available at all locations due to individual dentist's scope of practice. Other Charges: The Member is responsible for the Co-payments for services listed in the following Schedule of Benefits. Services not listed will be billed to the Member at the dentist's usual and customary fee (U&C). Specialty Care Information: During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dental specialist. * Your SafeGuard selected general dentist is responsible for coordinating your dental care, and if necessary, referring you to a SafeGuard contracted specialist, and will submit all required documentation for any necessary referral. Pedodontics: Pedodontic services listed as covered services in this Schedule of Benefits are available at a Specialist at 75% of that provider’s usual fee for children under the age of six (6) when referred by a SafeGuard selected general dentist. i If you choose to receive this service from a SafeGuard contracted specialty care provider (periodontics, oral surgery, endodontics, orthodontics), your co-payment will be 75% of that provider’s usual fee for this service. Benefit Summary for Specialty Care Calendar Year Limit $500/Person Limit per Lifetime $2,000/Person Co-payment Co-payment When Services When Services Performed by Performed by Contracted Contracted General Dentist Specialist Code Service • • • • D0120 D0140 D0145 Diagnostic Treatment Bitewings are limited to 1 per 12 months. Full mouth x-rays are limited to 1 per 3 years. Panoramic x-rays are limited to 1 per 3 years. Orthodontic x-rays are not covered. Periodic oral evaluation - established patient Limited oral evaluation - problem focused Oral evaluation for a patient under three years of age and counseling with primary caregiver GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 $4 $4 $4 $50 $50 $50 CA 1 SCHEDULE OF BENEFITS (continued) Co-payment Co-payment When Services When Services Performed by Performed by Contracted Contracted General Dentist Specialist Code Service D0150 D0180 Comprehensive oral evaluation - new or established patient Comprehensive periodontal evaluation - new or established patient Office visit - per visit (including all fees for sterilization and/or infection control) • $4 $5 $50 $5 $0 $0 D0210 D0220 D0230 D0240 D0270 D0272 D0273 D0274 D0330 Radiographs/Diagnostic Imaging (X-rays) Intraoral – complete series (including bitewings) Intraoral – periapical first film Intraoral – periapical each additional film Intraoral – occlusal film Bitewing – single film Bitewings – two films Bitewings – three films Bitewings – four films Panoramic film $5 $2 $0 $0 $2 $3 $3 $4 $10 $48 $16 $8 i i i i i $33 D0460 D0470 Tests and Examinations Pulp vitality tests Diagnostic casts $0 $30 i i $22 $22 $5 $5 i i i i $0 $12 $100 $140 $125 $150 $25 $25 i i i i i i i i $36 $47 $55 $68 $49 $60 i i i i i i D1330 D1351 D1510 D1515 D1520 D1525 D1550 D1555 Preventive Services Prophylaxis are limited to 2 per 12 months. Fluoride treatments are limited to 2 per 12 months for children under age 18. Space maintainers are limited to children under age 14. Prophylaxis – adult Prophylaxis – child Topical application of fluoride – child Topical fluoride varnish; therapeutic application for moderate to high caries risk patients Oral hygiene instructions Sealant – per tooth Space maintainer – fixed – unilateral Space maintainer – fixed – bilateral Space maintainer – removable – unilateral Space maintainer – removable – bilateral Re-cementation of space maintainer Removal of fixed space maintainer D2140 D2150 D2160 D2161 D2330 D2331 Restorative Treatment Amalgam – one surface, primary or permanent Amalgam – two surfaces, primary or permanent Amalgam – three surfaces, primary or permanent Amalgam – four or more surfaces, primary or permanent Resin-based composite – one surface, anterior Resin-based composite – two surfaces, anterior • • • D1110 D1120 D1203 D1206 GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 2 SCHEDULE OF BENEFITS (continued) Co-payment Co-payment When Services When Services Performed by Performed by Contracted Contracted General Dentist Specialist Code Service D2332 D2335 Resin-based composite – three surfaces, anterior Resin-based composite – four or more surfaces or involving incisal angle (anterior) Resin-based composite – one surface, posterior Resin-based composite – two surfaces, posterior Resin-based composite – three surfaces, posterior Resin-based composite – four or more surfaces, posterior D2391 D2392 D2393 D2394 • D2750 D2751 D2752 D2780 D2781 D2782 D2790 D2791 D2792 D2910 D2915 D2920 D2930 D2931 D2940 D2950 D2951 D2952 D2954 D2961 D2962 D2970 D2971 D3110 D3120 D3220 D3310 D3320 Crowns Cost of noble or high noble metal (gold, etc.) may be charged extra when used, not to exceed actual laboratory cost of metal. Crown – porcelain fused to high noble metal Crown – porcelain fused to predominantly base metal Crown – porcelain fused to noble metal Crown – ¾ cast high noble metal Crown – ¾ cast predominantly base metal Crown – ¾ cast noble metal Crown – full cast high noble metal Crown – full cast predominantly base metal Crown – full cast noble metal Recement inlay, onlay, or partial coverage restoration Recement cast or prefabricated post and core Recement crown Prefabricated stainless steel crown – primary tooth Prefabricated stainless steel crown – permanent tooth Protective restoration Core buildup, including any pins Pin retention – per tooth, in addition to restoration Post and core in addition to crown, indirectly fabricated Prefabricated post and core in addition to crown Labial veneer (resin laminate) – laboratory Labial veneer (porcelain laminate) – laboratory Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture framework Endodontics Pulp cap – direct (excluding final restoration) Pulp cap – indirect (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) GCERT2010-DHMO-SOB sob $75 $94 i i $65 $85 $110 $135 i i i i $460 $400 $440 $455 $395 $435 $420 $360 $400 $30 $30 $30 $82 $95 $31 $82 $18 $130 $100 $375 $400 $0 $228 i i i i i i i i i i i i i i i i i i i i i i i $24 $23 $53 i i i $230 $285 $375 $440 Customer Service (800) 880-1800 3 SCHEDULE OF BENEFITS (continued) Co-payment Co-payment When Services When Services Performed by Performed by Contracted Contracted General Dentist Specialist Code Service D3330 D3351 Endodontic therapy, molar (excluding final restoration) Apexification/recalcification/pulpal regeneration – initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) Apexification/recalcification/pulpal regeneration – interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) Apicoectomy/periradicular surgery – anterior Apicoectomy/periradicular surgery – bicuspid (first root) Apicoectomy/periradicular surgery – molar (first root) Apicoectomy/periradicular surgery (each additional root) Retrograde filling – per root Root amputation – per root Hemisection (including any root removal), not including root canal therapy D3352 D3353 D3410 D3421 D3425 D3426 D3430 D3450 D3920 D4210 D4211 D4260 D4261 D4341 D4342 D4355 D4381 D4910 • D5110 D5120 D5130 D5140 D5211 Periodontics Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant Osseous surgery (including flap entry and closure)-four or more contiguous teeth or tooth bounded spaces per quadrant Osseous surgery (including flap entry and closure)-one to three contiguous teeth or tooth bounded spaces per quadrant Periodontal scaling and root planing – four or more teeth per quadrant Periodontal scaling and root planing – one to three teeth per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report Periodontal maintenance Initial periodontal charting for moderate to advances cases Removable Prosthodontics Includes all adjustments for up to six (6) months post-delivery. Complete denture – maxillary Complete denture – mandibular Immediate denture – maxillary Immediate denture – mandibular Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) GCERT2010-DHMO-SOB sob $400 $105 $575 $115 $70 $115 $120 $115 $190 $210 $240 $95 $75 U&C U&C $375 $375 $375 $110 $100 $190 $190 $215 $520 $140 $240 $375 $675 $300 $540 $85 $140 $68 $112 $57 i $40 i $46 $5 i i $475 $475 $525 $525 $375 i i i i i Customer Service (800) 880-1800 4 SCHEDULE OF BENEFITS (continued) Co-payment Co-payment When Services When Services Performed by Performed by Contracted Contracted General Dentist Specialist Code Service D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Maxillary partial denture – flexible base (including any clasps, rests and teeth) Mandibular partial denture – flexible base (including any clasps, rests and teeth) Adjust complete denture – maxillary Adjust complete denture – mandibular Adjust partial denture – maxillary Adjust partial denture – mandibular Repair broken complete denture base Replace missing or broken teeth – complete denture (each tooth) Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth – per tooth Add tooth to existing partial denture Add clasp to existing partial denture Rebase complete maxillary denture Rebase complete mandibular denture Rebase maxillary partial denture Rebase mandibular partial denture Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) Interim partial denture (maxillary) Interim partial denture (mandibular) Tissue conditioning, maxillary Tissue conditioning, mandibular D5213 D5214 D5225 D5226 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5820 D5821 D5850 D5851 $375 i $525 i $525 i $375 i $375 i $26 $26 $26 $26 $57 $52 i i i i i i $57 $80 $75 $52 $67 $83 $175 $175 $165 $165 $110 $110 $105 $105 $150 $150 $150 $150 $200 $200 $55 $55 i i i i i i i i i i i i i i i i i i i i i i Crowns/Fixed Bridges - Per Unit GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 5 SCHEDULE OF BENEFITS (continued) Code • D6210 D6211 D6212 D6240 D6241 D6242 D6750 D6751 D6752 D6780 D6781 D6782 D6790 D6791 D6792 D6930 D6970 D6972 D6973 D7111 D7140 D7210 D7220 D7230 D7240 D7250 D7510 D7530 D7550 D7910 D7960 D7963 D7970 Co-payment Co-payment When Services When Services Performed by Performed by Contracted Contracted General Dentist Specialist Service Cost of noble or high noble metal (gold, etc.) may be charged extra when used, not to exceed actual laboratory cost of metal. Pontic – cast high noble metal Pontic – cast predominantly base metal Pontic – cast noble metal Pontic – porcelain fused to high noble metal Pontic – porcelain fused to predominantly base metal Pontic – porcelain fused to noble metal Crown – porcelain fused to high noble metal Crown – porcelain fused to predominantly base metal Crown – porcelain fused to noble metal Crown – ¾ cast high noble metal Crown – ¾ cast predominantly base metal Crown – ¾ cast noble metal Crown – full cast high noble metal Crown – full cast predominantly base metal Crown – full cast noble metal Recement fixed partial denture Post and core in addition to fixed partial denture retainer, indirectly fabricated Prefabricated post and core in addition to fixed partial denture retainer Core build up for retainer, including any pins Oral Surgery Extraction, coronal remnants – deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Removal of impacted tooth – soft tissue Removal of impacted tooth – partially bony Removal of impacted tooth – completely bony Surgical removal of residual tooth roots (cutting procedure) Incision and drainage of abscess – intraoral soft tissue Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue Partial ostectomy/sequestrectomy for removal of non-vital bone Suture of recent small wounds up to 5 cm Frenulectomy – also known as frenectomy or frenotomy – separate procedure not incidental to another procedure Frenuloplasty Excision of hyperplastic tissue – per arch GCERT2010-DHMO-SOB sob $420 $360 $400 $460 $400 $440 $460 $400 $440 $455 $395 $435 $420 $360 $400 $46 $130 i i i i i i i i i i i i i i i i i $100 i $87 i $35 $44 $48 $60 $83 $95 $95 $132 $170 $90 U&C U&C $130 $170 $185 $130 i i U&C i U&C $130 i i $130 U&C i i Customer Service (800) 880-1800 6 SCHEDULE OF BENEFITS (continued) Code D8030 D8040 D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8693 D9110 D9120 D9215 D9310 D9430 D9440 D9450 D9930 D9941 D9942 D9951 D9972 Co-payment Co-payment When Services When Services Performed by Performed by Contracted Contracted General Dentist Specialist Service Orthodontics Limited orthodontic treatment of the adolescent dentition Limited orthodontic treatment of the adult dentition Comprehensive orthodontic treatment of the adolescent dentition Comprehensive orthodontic treatment of the adult dentition Removable appliance therapy Fixed appliance therapy Pre-orthodontic treatment visit Periodic orthodontic treatment visit (as part of contract) Orthodontic retention (removal of appliances, construction and placement of retainer(s)) Rebonding or recementing; and/or repair, as required, of fixed retainers Adjunctive General Services Palliative (emergency) treatment of dental pain – minor procedure Fixed partial denture sectioning Local anesthesia in conjunction with operative or surgical procedures Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician Office visit for observation (during regularly scheduled hours) – no other services performed Office visit – after regularly scheduled hours Case presentation, detailed and extensive treatment planning Treatment of complications (post-surgical) - unusual circumstances, by report Fabrication of athletic mouthguard Repair and/or reline of occlusal guard Occlusal adjustment – limited External bleaching – per arch Missed Appointments – without twenty-four (24) hour prior notice Record transfer - transfer of all materials with less than a full mouth x-ray Record transfer - transfer of all materials with a full mouth xray U&C U&C U&C $1,450 $1,550 $2,200 U&C $262 $305 U&C $25 U&C $2,400 i i $40 $0 $175 U&C $0 $35 $50 $0 $0 i $0 $50 $50 $6 i $52 $5 U&C i $5 $17 $135 $52 $40 $175 $20 i i $70 i $22 $10 $10 $20 $20 Current Dental Terminology © American Dental Association i If you choose to receive this service from a SafeGuard contracted specialty care provider (periodontics, oral surgery, endodontics, orthodontics), your co-payment will be 75% of that provider’s usual fee for this service. GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 7 DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES The limitations listed below apply to your dental plan. However, you may elect to have any treatment performed at the dentist's regular fee: 1. Services performed by a general dentist or specialty care dentist, not contracted with SafeGuard, without prior approval by SafeGuard (except for out of area emergency services). 2. Routine and periodic examinations are limited to two (2) per twelve (12) months, per enrolled Member. 3. Routine prophylaxis procedures are limited to two (2) per twelve (12) months. 4. Bitewing radiographs (x-rays) in conjunction with periodic examinations are limited to one (1) series of films in any twelve (12) consecutive month period. Full mouth radiographs (x-rays), in conjunction with periodic examinations, are limited to once every three (3) years. Panoramic films are limited to once every three (3) years. 5. Fluoride treatment is limited to enrolled Members under the age of eighteen (18) years, and two (2) per twelve (12) months. 6. Periodontal scaling and root planing, and/or gingival curettage, and periodontal maintenance procedures are limited to one (1) course of therapy during any twelve (12) month period. 7. Space maintainers are limited to enrolled Members under the age of fourteen (14) years. 8. Partial dentures are not eligible for replacement within three (3) years of original placement unless required as a result of tooth loss which cannot be restored by modification of the existing partial denture. Crowns, bridges, and/or complete dentures are not eligible for replacement within five (5) years of original placement. 9. Complete upper and/or lower dentures are covered only once within any five (5) year period. Replacement will be provided for an existing denture only if it is unsatisfactory and cannot be made satisfactory. Complete or partial upper and/or lower dentures are limited to the benefit level for a standard procedure. If a more personalized or specialized treatment (such as precision attachments, overlays, implants, personalization or characterization) is chosen by the patient and the dentist, the patient will be responsible for all additional charges. 10. Complete and/or partial denture relines are limited to one (1) per denture during a twelve (12) month period. 11. Pedodontic services are available to eligible Members under the age of six (6) years, if his or her assigned Participating General Dentist requests the referral to the participating Specialist after examining the patient. Pedodontic benefits are available at a reduced rate from participating dental offices. 12. Plan contribution towards the cost of specialty care as a result of an approved referral is limited to a maximum of $500 per contract year. Lifetime maximum of $2,000. GCERT2010-DHMO-SOB limit Customer Service (800) 880-1800 8 DENTAL BENEFITS: EXCLUSIONS The following dental services and procedures are not included in this dental plan and there is no coverage for these items. However, you may elect to have any treatment performed at the dentist's regular fee: 1. Any procedure not specifically listed as a covered benefit. 2. Any condition for which benefits of any nature are recovered or found to be recoverable, whether by adjudication or settlement, medical health insurance, worker's compensation or occupational disease law, even if the patient did not claim those benefits. 3. Care or treatment which is obtained from, or for which payment is made by, any Federal, State, County, Municipal, or other governmental agency, including any foreign government. 4. Disease contracted or injuries sustained as a result of a major disaster, war, declared or undeclared, epidemic conditions, or from exposure to nuclear energy, whether or not the result of war. 5. Any illness, injury, or condition for which a third party may be liable or legally responsible by reason of negligence, an intentional act or breach of any legal obligation on the part of such third party is not covered. 6. Dental treatment or expenses incurred or in connection with any dental procedures started prior to the Member's effective date under this Plan or after termination of the Member's coverage. Example: teeth prepared for crowns, root canal treatment in progress, orthodontic treatment in progress. 7. Dispensing of drugs not normally supplied in the dental office. 8. Hospital and associated physician charges or any kind of charges for any dental treatment or costs associated with treatment as a result of an accident. This plan does not provide emergency medical care to its members, except, if applicable, in certain specifically identified instances. Members are encouraged to use the 911 emergency response system in areas where the system is established and operating when the Member has an emergency medical condition that requires an emergency response. 9. All treatment of fractures and dislocations. 10. Extractions for orthodontic purposes. 11. General anesthesia, inhalation sedation, intravenous sedation, or intramuscular sedation. 12. Dental treatment or expenses incurred in conjunction with the correction of congenital or developmental malformations. 13. Histopathological exams, treatment and/or removal of cysts, tumors, neoplasms, malignancies and foreign bodies. 14. Tooth implantation or transplantation, orthognathic surgery, soft tissue or osseous grafts, alveoloplasty, vestibuloplasty, or osteotomy procedures. 15. Charges for any dental treatment, because the Member is unwilling or incapable of having treatment performed in the assigned general dentist or specialist office. 16. Dental procedures and charges incurred as part of implants (placement or removal) and prosthetic devices placed on implants (fixed or removable, example: bridges, crowns, dentures). 17. Replacement of lost or stolen dentures, crown and bridgework, or other dental appliances. 18. Precision attachments and stress breakers. 19. Crown lengthening surgical procedures. GCERT2010-DHMO-SOB exclusions Customer Service (800) 880-1800 9 DENTAL BENEFITS: EXCLUSIONS 20. Periodontal irrigation procedures, when available, are provided at the doctor's regular fee. 21. Dental treatment or procedures required in conjunction with altering vertical dimension, replacing tooth structure lost by attrition, erosion or abrasion. 22. Dental treatment or procedures requiring or associated with fixed prosthodontic restorations when part of extensive oral rehabilitation or reconstruction (more than six (6) units of crown and/or bridgework in one (1) arch or more than ten (10) units total). Extensive oral rehabilitation or reconstruction is available at the dentist's regular fee. 23. Diagnosis or treatment by any method of any condition related to the jaw joint, temporomandibular joint (TMJ) or associated musculature, nerves and other tissues. 24. Oral physio-therapy, dietary or saliva analysis and dietary instruction. 25. The treating dentist shall have the right to discontinue further treatment of a Member who continually fails to keep appointments or who fails to follow their prescribed course of treatment. 26. A dental treatment plan which in the opinion of the Participating Dentist, is not dentally necessary, will not produce a beneficial result, or has a poor prognosis. 27. Any corrective treatment required as a result of dental services performed by a non-participating dentist while this coverage is in effect, and any dental services started by a non-participating dentist will not be the responsibility of the participating dental office or the Plan for completion or compensation. 28. Endodontic retreatment of previous root canal therapy is not a covered benefit. 29. Orthodontic Exclusions & Limitations Limitations A. Child co-payments apply only to those members up to age nineteen (19). Age nineteen (19) and older are considered adults and are subject to adult co-payments. Age is determined on the date bands are placed. B. Treatment co-payments are for twenty-four (24) months of treatment. Treatment in excess of twentyfour (24) months (extended treatment) is available at usual and customary fees, payable until treatment is completed (retainers are placed). If the patient is in active treatment and the member elects to change providers, the member may incur additional expenses. C. Member and his or her eligible dependent must remain on the plan during the period of time the member or his or her eligible dependent is undergoing orthodontic treatment. An early termination will result in usual and customary charges for all unfinished work. D. Orthodontic treatment must be provided by participating Orthodontist. Exclusions A. The following are not benefits included as orthodontia: 1. Study Models 2. X-rays for orthodontic purposes 3. Tracings and photographs 4. Phase I orthodontic treatment (prior to full mouth banding) B. Treatment in progress started prior to a Member's eligibility under this Plan. C. Surgical procedures for orthodontic treatment. GCERT2010-DHMO-SOB exclusions Customer Service (800) 880-1800 10 DENTAL BENEFITS: EXCLUSIONS D. Severe or mutilated malocclusions. E. Retreatment of orthodontic cases. F. Changes in treatment necessitated by accident of any kind. G. Hospital charges, or treatment in a hospital. H. Dispensing of drugs not normally supplied in a dental office. I. Treatment of temporomandibular joint (TMJ) disturbances, hormonal imbalances, cleft palate, micrognathia, macroglossia, and myofunctional therapies are excluded services. J. Replacement of lost or broken appliances. K. Extractions for orthodontic purposes GCERT2010-DHMO-SOB exclusions Customer Service (800) 880-1800 11 LANGUAGE ASSISTANCE As a SafeGuard member you have a right to free language assistance services, including interpretation and translation services. SafeGuard collects and maintains your language preferences, race, and ethnicity so that we can communicate more effectively with our members. If you require language assistance or would like to inform SafeGuard of your preferred language, please contact SafeGuard at (800) 880-1800. Como miembro de SafeGuard usted tiene derecho a recibir servicios gratuitos de asistencia en idiomas. Esto incluye servicios de interpretación y traducción. SafeGuard recaba la información sobre sus preferencias de idioma, raza, y etnia de manera que nos podamos comunicar eficazmente con nuestros afiliados. Si necesita asistencia en su idioma o quiere informarle a SafeGuard sobre su idioma de preferencia, comuníquese con SafeGuard al (800) 880-1800. Evidence of Coverage and Disclosure Statement Individual Dental Plan SG-INDIV-EOC 1 CA 12/07 8/08 Evidence of Coverage and Disclosure Statement This Evidence of Coverage provides a detailed summary of how your SafeGuard dental plan operates, your entitlements, and the plan’s restrictions and limitations. However, this combined Evidence of Coverage and Disclosure Statement constitutes only a summary of the health plan. The health plan contract must be consulted to determine the exact terms and conditions of coverage. This Evidence of Coverage and Disclosure Statement is subject to Chapter 2.2 of Division 2 of the California Health and Safety Code (commonly referred to as the Knox-Keene Act) and the regulations issued thereto by the Department of Managed Health Care. Should either the law or the regulations be amended, such amendments shall automatically be deemed to be a part of this document and shall take precedence over any inconsistent provision of this contract. Any provision required to be in this Evidence of Coverage and Disclosure Statement by either law or the regulation shall automatically bind SafeGuard. Entire Contract SafeGuard typically contracts with an Individual, such as yourself to provide benefits. Your application, Enrollment Form, this Evidence of Coverage and any attachments or inserts including the Schedule of Benefits with Exclusions and Limitations, constitutes the entire agreement between the parties. To be valid, any change in the contract must be approved by an officer of SafeGuard and attached to it. No agent may change the Contract or waive any of the provisions. Should any provision herein not conform to applicable laws, it shall be construed as if it were in full compliance thereof. SG-INDIV-EOC 2 CA 12/07 8/08 Evidence of Coverage and Disclosure Statement Table of Contents Who May Enroll .................................................................................. 4 Service Area ...................................................................................... 4 Dependent Coverage .......................................................................... 4 When Coverage Begins ...................................................................... 4 Choice of Provider .............................................................................. 5 Facilities ........................................................................................... 5 New Patient and Routine Services ...................................................... 5 Making an Appointment ...................................................................... 5 Uniform Health Plan Benefits and Coverage Matrix ............................... 6 Specialist Referrals ............................................................................ 6 Changing Your Selected General Dental Office ...................................... 6 Second Opinions ................................................................................ 7 Prepayment Fee ................................................................................. 8 Co-payments ..................................................................................... 8 Other Charges ................................................................................... 8 Coordination of Benefits ..................................................................... 8 Customer Service .............................................................................. 8 Emergency Dental Services ................................................................ 8 Grievance Procedures ....................................................................... 10 Arbitration ....................................................................................... 11 Termination of Benefits .................................................................... 11 Renewal Provisions .......................................................................... 12 Reinstatement ................................................................................ 12 Current Members ............................................................................. 13 New Members ................................................................................. 13 Member Rights ................................................................................ 14 Member Responsibilities .................................................................. 14 Language Assistance ....................................................................... 15 Definitions. ...................................................................................... 16 SG-INDIV-EOC 3 CA 12/07 8/08 Who May Enroll You may enroll yourself and your dependents, provided each meets eligibility requirements and/or the Service Area and Dependent Coverage requirements listed below. Service Area The Service Area is the geographical area in which SafeGuard has a panel of Selected General Dentists and Specialists who have agreed to provide care to SafeGuard members. To enroll in the SafeGuard plan, you must reside, live, or work in the Service Area, and the permanent legal residence of any enrolled dependents must be: • The same as yours; • In the Service Area with the person having temporary or permanent conservatorship or guardianship of such dependents, where the Subscriber has legal responsibility for the health care of such dependents; • In the Service Area under other circumstances where you are legally responsible for the health care of such dependents; or • In the Service Area with your spouse. Dependent Coverage SafeGuard defines eligible dependents to be: • Your lawful spouse or registered domestic partner. • Your unmarried children or grandchildren up to age 25 for whom you provide care (including adopted children, step-children, or other children for whom you are required to provide dental care pursuant to a court or administrative order). • Your children who are incapable of self-sustaining employment and support due to a developmental disability or physical handicap. When Coverage Begins Coverage for you and your enrolled dependents will begin on the date in your enrollment materials. Newborn children are covered the first day of the month following the date of birth and legally adopted children, foster children and stepchildren are covered the first day of the month following placement as long as SafeGuard is notified within thirty (30) days and any prepayment fee is paid within that period. SG-INDIV-EOC 4 CA 12/07 8/08 Choice of Provider When you enroll in the SafeGuard plan, you and each enrolled family member must choose a Selected General Dental Office from our SafeGuard network. Each family member may select a different dental office. Please refer to the Directory of Participating Dentists for a complete listing of Selected General Dental Offices. Or you may access our website at www.safeguard.net to view SafeGuard General Dentists in your home or work zip codes. Facilities A complete list of contracted facilities is contained in the Directory of Participating Dentists. New Patient and Routine Services As a SafeGuard member, you have the right to expect that the first available appointment time for new patient or routine dental care services is within four (4) weeks of your initial request. If your schedule requires that an appointment be scheduled on a specific date, day of the week, or time of day, the Selected General Dentist may need additional time to meet your special request. Making an Appointment Once your coverage begins, you may contact the Selected General Dental Office you selected at enrollment to schedule an appointment. SafeGuard Selected General Dental Offices are open in accordance with their individual practice needs. When scheduling an appointment, please identify yourself as a SafeGuard member. Your Selected General Dental Office will also need to know your chief dental concern and basic personal data. Arrive early for your first appointment to complete any paperwork. There is an office visit co-payment on some plans and also be aware that there is a charge for missing your appointment. Your first visit to your dentist will usually consist of x-rays and an examination only. By performing these procedures first, your dentist can establish your treatment plan according to your overall health needs. We recommend that you take this brochure with you on your appointment, along with the enclosed Schedule of Benefits. Remember, only dental services listed as covered benefits in the Schedule of Benefits and provided by a SafeGuard Dentist are covered. SG-INDIV-EOC 5 CA 12/07 8/08 Uniform Health Plan Benefits and Coverage Matrix This matrix is designed to help you compare covered benefits and is a summary only. Please review this Evidence of Coverage and the Schedule of Benefits for a detailed description of covered benefits, exclusions and limitations. Category Deductibles Co-payments and Limitations Your plan may have a deductible (co-payment) for services listed in your plan’s Schedule of Benefits. Lifetime Maximums Not applicable. Professional Services Covered professional ser vices are provided by Participating Dentists. Emergency Health Coverage Not applicable. Ambulance Services Not applicable. Prescription Drug Coverage Not applicable. Durable Medical Equipment Not applicable. Mental Health Services Not applicable. Chemical Dependency Services Not applicable. Home Health Services Not applicable. Other Please review your plan’s Schedule of Benefits for more details on covered services. Specialist Referrals During the course of treatment, you may require the services of a Specialist. Your Selected General Dental Office will submit all required documentation to SafeGuard and SafeGuard will advise you of the name, address, and telephone number of the Specialist who will provide the required treatment. These services are available only when the dental procedure cannot be performed by the Selected General Dental Office due to the severity of the problem. Some SafeGuard plans require that specialty referrals be authorized in writing from SafeGuard while others incorporate a direct or self-referral process. Full information is contained in your plan Schedule of Benefits. Changing Your Selected General Dental Office You have control over your choice of dental offices, and you can make changes at any time. If you would like to change your Selected General Dental Office, please contact Customer Service at (800) 880-1800. Our associates will help you locate a dental office most convenient to you. The transfer will be effective on the first day of the month following the transfer request. You must pay all outstanding charges owed to your dentist before you transfer to a new dentist. In addition, you may have to pay a fee for the cost of duplicating your x-rays and dental records. SG-INDIV-EOC 6 CA 12/07 8/08 $ 192.96 $ 288.96 $ 397.92 Subscriber Only Subscriber + One Subscriber + Family $ 17.00 $ 25.20 $ 34.50 Subscriber Only Subscriber + One Subscriber + Family +$16.00 $ 141.00 $ 114.96 $ 69.96 SM600 First Name +$16.00 $ 13.00 $ 10.40 $ 6.65 SM600 Birthdate Facility # - 2nd Choice Must be completed to enroll in plan(s) Facility # - 1st Choice Step 2. Select a payment option Sex Annual by credit card CID # ______ Expiration Date _____ / ____ Date: Signature: Date: I hereby authorize SafeGuard Health Plans, Inc., to debit the designated prepayment fee each month from my bank account. This authorization will remain in effect until I notify SafeGuard, in writing, 30 days prior to termination. My bank is authorized to make any necessary corrections. Automatic Bank Account payments are deducted on or about the 20th of each month. Monthly by checking account (Include check for first month’s payment. This is the account number we will use for your monthly bank debit.) Signature: I hereby authorize credit card payment in the amount indicated on this application: Name as it appears on credit card: Credit Card Number Please charge my: VISA MasterCard Discover American Express Monthly by credit card Annual by check made payable to SmileSaver (include with application) MI - Facility # - 2nd Choice Ext. Select up to 3 dentists, 3 orthodontists and 1 vision care provider per family ) Zip Code Apt. # - Master General #: Subscriber SS# Facility # - 1st Choice Work Telephone ( MI SM-IND-FAM-EF Signature: Mail this application to: SmileSaver - DAIS 3720 S. Susan St. #200 Santa Ana, CA 92704 SmileSaversm Dental & Vision products are provided by SafeGuard Health Plans, Inc. Visit SafeGuard’s website at www.safeguard.net for current provider listings Date: I understand that the initial term of the plan contract is for one year. 4/07 Authorization to release dental/vision records - I hereby authorize the release and disclosure to review, or to obtain a copy of, any and all dental records which pertain to me or any member of my family, maintained by my chosen selected provider and/or specialist, to SafeGuard and/or any designated agent or representative for the purposes of dental treatment, care and for SafeGuard’s quality assessment and utilization reviews, which will be kept strictly confidential. This authorization shall remain valid for the term of this coverage. Use and Disclosure of Personal Health Information: Agreement - I understand that any dispute or controversy which may arise between SafeGuard Health Plans, Inc., a California Corporation and myself, may be submitted to binding arbitration in lieu of a jury or court trial. Total Amount $__________ One-time application fee (non-refundable) SM400 Dental Monthly Rates: ) State General Agent #: Must be completed to enroll: Total Amount $ __________ One-time application fee (non-refundable) SM400 Dental Broker #: First Name Home Telephone ( SM600 Step 1. Select a rate Annual Rates: Child #4 Child #3 Child #2 Child #1 Spouse Last Name Dependent Information: SM400 Date of Birth Plan Selected: Dental: Male/Female City Home Address Last Name To ensure that you’re correctly enrolled in the plan(s) you have selected, make sure to fill the form out completely. We cannot guarantee access to care if information is missing. With these plans, care is provided by a network dentist ... make sure you include the facility number for the providers you’ve chosen. SmileSaver Individual & Family Enrollment Application Monthly credit card draft: If your application and payment is received by the 20th of the month, you will be able to use your benefits on the first day of the following month (e.g. received by March 20, your benefits will be effective April 1. After the 20th of March, your benefits will be effective May 1). Monthly bank draft: If your application and payment is received by the 10th of the month, you will be able to use your benefits on the first day of the following month (e.g. received by March 10, your benefits will be effective April 1. After the 10th of March, your benefits will be effective May 1). Annually by check or credit card: If your application and payment is received by the 20th of the month, you will be able to use your benefits on the first day of the following month (e.g. received by March 20, your benefits will be effective April 1). The date your SmileSaver coverage becomes effective is based on when we receive your application and payment. If you have questions after reviewing the following information, call us at 800.445.8119. Effective Dates of Coverage Second Opinions You may request a second opinion if you have unanswered questions about diagnosis, treatment plans, and/or the results achieved by such dental treatment. Contact SafeGuard’s Customer Service Department either by calling (800) 880-1800 or sending a written request to the following address: SafeGuard c/o Customer Service PO Box 3594 Laguna Hills, CA 92654-3594 In addition, your Selected General Dentist or SafeGuard may also request a second opinion on your behalf. There is no second opinion consultation charge to you. You will be responsible for the office visit co-payment as listed on your Schedule of Benefits. Reasons for a second opinion to be provided or authorized shall include, but are not limited to, the following: (1) If you question the reasonableness or necessity of recommended surgical procedures. (2) If you question a diagnosis or plan of care for a condition that threatens loss of life, loss of limb, loss of bodily function, or substantial impairment, including, but not limited to, a serious chronic condition. (3) If the clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to conflicting test results, or the treating dentist is unable to diagnose the condition, and the enrollee requests an additional diagnosis. (4) If the treatment plan in progress is not improving your dental condition within an appropriate period of time given the diagnosis and plan of care, and you request a second opinion regarding the diagnosis or continuance of the treatment. Requests for second opinions are processed within five (5) business days of receipt by SafeGuard of such request, except when an expedited second opinion is warranted; in which case a decision will be made and conveyed to you within 24 hours. Upon approval, SafeGuard will contact the consulting dentist and make arrangements to enable you to schedule an appointment. All second opinion consultations will be completed by a contracted dentist with qualifications in the same area of expertise as the referring dentist or dentist who provided the initial examination or dental care services. You may obtain a copy of the second dental opinion policy by contacting SafeGuard’s Customer Service Department by telephone at the toll-free number indicated above, or by writing to SafeGuard at the above address. SG-INDIV-EOC 7 CA 12/07 8/08 No co-payment is required for a second opinion consultation. Some plans do require a co-payment for an office visit. Your Financial Responsibility: Prepayment Fee Your prepayment fee is the amount you pay SafeGuard for your dental benefits. It is due and payable either annually or by monthly bank draft, according to your agreement with SafeGuard. Please refer to the co-payment section, below, for information relating to your co-payments under this plan. The prepayment fee is not the same as a co-payment. Co-payments When you receive care from either a Selected General Dentist or Specialist, you will pay the co-payment described on your Schedule of Benefits enclosed with this Evidence of Coverage. When you are referred to a Specialist, your co-payment may be either a fixed dollar amount, or a percentage of the dentist’s usual and customary fee. Please refer to the Schedule of Benefits for specific details. When you have paid the required co-payment, if any, you have paid in full. If SafeGuard fails to pay the contracted provider, you will not be liable to the provider for any sums owed by SafeGuard. If you choose to receive services from a non-contracted provider, you may be liable to the non-contracted provider for the cost of services unless specifically authorized by SafeGuard or in accordance with emergency care provisions. SafeGuard does not require claim forms. Other Charges All other charges you may be required to pay under this plan are listed in the Schedule of Benefits. Coordination of Benefits SafeGuard does not coordinate benefits with any other carrier. If you have coverage with another carrier, please contact that carrier to determine whether coordination of benefits is available. Customer Service SafeGuard provides toll-free access to our Customer Service Associates to assist you with benefit coverage questions, resolving problems or changing your dental office. SafeGuard’s Customer Service can be reached Monday through Friday at (800) 880-1800 from 5:00 a.m. to 6:00 p.m. Pacific Time. Automated service is also provided after hours for eligibility verification and dental office transfers. Emergency Dental Services Emergency dental services are dental procedures administered in a dentist’s office, dental clinic, or other comparable facility, to evaluate and stabilize SG-INDIV-EOC 8 CA 12/07 8/08 dental conditions of a recent onset and severity accompanied by excessive bleeding, severe pain, or acute infection that would lead a reasonably prudent lay person possessing average knowledge of dentistry to believe that immediate care is needed. All Selected General Dental Offices provide emergency dental services twentyfour (24) hours a day, seven (7) days a week and SafeGuard encourages you to seek care from your Selected General Dentist. If you require emergency dental services, you may go to any dental provider, go to the closest emergency room, or call 911 for assistance, as necessary. Prior Authorization for emergency dental services is not required. Your reimbursement from SafeGuard for emergency dental services, if any, is limited to the extent the treatment you received directly relates to emergency dental services – i.e. to evaluate and stabilize the dental condition. All reimbursements will be allocated in accordance with your plan benefits, subject to any exclusions and limitations. Hospital charges and/or other charges for care received at any hospital or outpatient care facility that are not related to treatment of the actual dental condition are not covered benefits. If you receive emergency dental services, you will be required to pay the charges to the dentist and submit a claim to SafeGuard for a benefits determination. If you seek emergency dental services from a provider located more than 25 miles away from your Selected General Dentist, you will receive emergency benefits coverage up to a maximum of $50, less any applicable co-payments. To be reimbursed for emergency dental services, you must notify Customer Service within forty-eight (48) hours after receiving such services. If your physical condition does not permit such notification, you must make the notification as soon as it is reasonably possible to do so. Please include your name, family ID number, address and telephone number on all requests for reimbursement. In the event of a dental emergency and you are within 25 miles of your Selected General Dental Office, simply contact your dentist who will make reasonable arrangements for such emergency dental care. If your dentist isn’t available, you must contact SafeGuard’s Customer Service Department at (800) 880-1800 for assistance. If you are more than twenty-five (25) miles from your chosen Selected General Dental Office, or you cannot reach your dentist or SafeGuard’s Customer Service, you may obtain emergency dental services from any licensed dentist. To be reimbursed for a dental emergency, you must notify Customer Service within forty-eight (48) hours after receiving dental emergency care services. If your physical condition does not permit such notification within the SG-INDIV-EOC 9 CA 12/07 8/08 prescribed time, the member must make the notification as soon as it is reasonably possible to do so. If you do not require emergency dental services and a delay in receiving treatment would not be detrimental to your health, please contact your Selected General Dental Office or SafeGuard’s Customer Service Department at (800) 880-1800 to make reasonable arrangements for your care. Grievance Procedures If you or one of your eligible dependents has a grievance with us or your dentist, you may orally submit such grievance by calling our Customer Service Department at (800) 880-1800. We will permit grievances which are filed within 180 days of the occurrence or incident that is the subject of the grievance. You may also submit a completed written grievance form (available by calling the Customer Service number) or a detailed summary of your grievance to: SafeGuard c/o Quality Management Department PO Box 3532 Laguna Hills, CA 92654-3532 You may also file a written grievance via our website at www.safeguard.net. Please click on Members, then Forms to Print, and then Grievance Forms. Please be sure to include your name (patient’s name, if different), Member Identification Number, facility (or Selected General Dental Office) name and number on all written correspondence. We agree, subject to our Complaint Procedure, to duly investigate and endeavor to resolve any and all complaints received from Members regarding the plan. We will confirm receipt of your complaint in writing within five (5) calendar days of receipt. We will resolve the complaint and communicate the resolution in writing within thirty (30) calendar days. The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-880-1800 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for SG-INDIV-EOC 10 CA 12/07 8/08 an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a tollfree telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web Site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. In the event of an urgent grievance, which involves an imminent and serious threat to your health, including, but not limited to, severe pain, potential loss of life, limb or major bodily function, you are not required to participate in SafeGuard’s grievance process and may directly contact the California Department of Managed Health Care, as referenced above, for review of the urgent grievance. Arbitration Each and every disagreement, dispute or controversy which remains unresolved concerning the construction, interpretation, performance or breach of this contract, or the provision of dental services under this contract after exhausting SafeGuard’s complaint procedures, arising between the organization, a member or the heir-at-law or personal representative of such person, as the case may be, and SafeGuard, its employees, officers or directors, or participating dentist or their dental groups, partners, agents, or employees, may be voluntarily submitted to arbitration in accordance with the American Arbitration Association rules and regulations, whether such dispute involves a claim in tort, contract or otherwise. This includes, without limitation, all disputes as to professional liability or malpractice, that is as to whether any dental services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered. It also includes, without limitation, any act or omission which occurs during the term of this contract but which gives rise to a claim after the termination of this contract. Arbitration shall be initiated by written notice to the President, SafeGuard Health Plans, Inc., P.O. Box 30900, Laguna Hills, California 92654-0900.The notice shall include a detailed description of the matter to be arbitrated. Changes To Your Coverage: Termination of Benefits Your coverage may be cancelled for any reason, after not less than 60 days written notice by either you or SafeGuard. Your coverage may be cancelled after not less than 30 days written notice for: • Non-payment of amounts due under the contract, except no written notice will be required for failure to pay premium. SG-INDIV-EOC 11 CA 12/07 8/08 • Failure to establish a satisfactory dentist-patient relationship and if it is shown that SafeGuard has, in good faith, provided you with the opportunity to select an alternative dentist. • Neither residing, living, or working in the service area or area for which SafeGuard is authorized to do business. Your coverage may be cancelled after not less than 15 days written notice for: • An intentional misrepresentation, except as limited by statute. • Fraud in the use of services or facilities. • Such other good cause as is agreed upon in the contract. Your coverage may be cancelled immediately: • Subject to continuation of coverage and conversion privilege provisions, if applicable, if you do not meet eligibility requirements other than the requirements that you live or work in the service area. • For any misconduct detrimental to safe plan operations and the delivery of services. If you fail to pay the prepayment fees through and including the final month of the contract, all coverage may be terminated at the end of the grace period, and you may be responsible for the usual and customary fees for any services received from your Selected General Dentist or Specialist during the period the prepayment fees went unpaid, including the grace period. Enrollment will be cancelled as of the last day for which payment has been received, subject to compliance with notice requirements. Orthodontic treatment is governed by the orthodontic limitations listed on your schedule of benefits. If you terminate coverage from the plan after the start of orthodontic treatment, you will be responsible for any additional incurred charges for any remaining orthodontic treatment. Renewal Provisions You have contracted with SafeGuard to provide services for the time period specified in the contract. Your coverage under the plan is guaranteed for that time period so long as you meet the eligibility requirements under the plan. When the contract expires, it may be renewed. If renewed, it is possible that the terms of the plan may have been changed. If changes to benefits, copayments or premiums have been made to a renewed contract, you will be notified you not less than thirty (30) days before the effective date. Reinstatement Receipt by SafeGuard of the proper prepaid or periodic payment after cancellation of the contract for non-payment shall reinstate the contract as SG-INDIV-EOC 12 CA 12/07 8/08 though it had never been cancelled if such payment is received on or before the due date of the succeeding payment. An enrollee or subscriber who alleges that his or her enrollment has been canceled or not renewed because of his or her health status or requirements for health care services may request a review by the Director of the California Department of Managed Health Care. If the Director determines that a proper complaint exists, the Director shall notify SafeGuard. Within 15 days after receipt of such notice, SafeGuard shall either request a hearing or reinstate the enrollee or subscriber. If, after a hearing, the Director determines that the cancellation or failure to renew is improper, the Director shall order SafeGuard to reinstate the enrollee or subscriber. A reinstatement pursuant to this provision shall be retroactive to the time of cancellation or failure to renew and SafeGuard shall be liable for the expenses incurred by the subscriber or enrollee for covered health care services from the date of cancellation or non-renewal to and including the date of reinstatement. Continuity of Care: Current Members Current members may have the right to the benefit of completion of care with their Terminated Provider for certain specificed dental conditions. Please call SafeGuard at (800) 880-1800 to see if you may be eligible for this benefit. You may request a copy of SafeGuard's Continuity of Care Policy. You must make a specific request to continue under the care of your Terminated Provider. We are not required to continue your care with that provider if you are not eligible under our policy or if we cannot reach agreement with your Terminated Provider on the terms regarding your care in accordance with California law. New Members New members may have the right to the benefit of completion of care with their Non-Participating Provider for certain specified dental conditions. Please call SafeGuard at (800) 880-1800 to see if you may be eligible for this benefit. You may request a copy of SafeGuard's Continuity of Care Policy. You must make a specific request to continue under the care of your NonParticipating Provider. We are not required to continue your care with that provider if you are not eligible under our policy or if we cannot reach agreement with your Non-Participating Provider on the terms regarding your care in accordance with California law. This policy does not apply to new members of an individual subscriber contract. You may obtain a copy of SafeGuard’s policy on continuation of care, which contains the specific information relating to the required qualifying events for receiving continuation of care, or you may receive information regarding your rights to continuation of care from our Customer Service Department by calling (800) 880-1800. If you have further questions, you are encouraged to contact the California Department of Managed Health Care, which protects HMO consumers, by telephone at its toll-free number, 1-888-HMO-2219, or at a SG-INDIV-EOC 13 CA 12/07 8/08 TDD number for the hearing impaired at 1-877-688-9891, or online at www.hmohelp.ca.gov. Member Rights During the term of the contract between you and SafeGuard, SafeGuard guarantees that it will not decrease any benefits, increase any co-payment, or change any exclusion or limitation. SafeGuard will not cancel or fail to renew your enrollment in this Plan because of your health condition or your requirements for dental care. Your Selected General Dental Office is responsible to you for all treatment and services, without interference from SafeGuard. However, your Selected General Dentist must follow the rules and limitations set up by SafeGuard and conduct his or her professional relationship with you within the guidelines established by SafeGuard. If SafeGuard’s relationship with your Selected General Dental Office ends, your dentist is obligated to complete any and all treatment in progress. SafeGuard will arrange a transfer for you to another dentist to provide for continued coverage under the Plan. As indicated on your enrollment form, your signature authorizes SafeGuard to obtain copies of your dental records, if necessary. As a member, you have the right to... • Be treated with respect, dignity and recognition of your need for privacy and confidentiality. • Express complaints and be informed of the complaint process. • Have access and availability to care and access to and copies of your dental records. • Participate in decision-making regarding your course of treatment. • Be provided information regarding Selected General Dental Offices. • Be provided information regarding the services, benefits and specialty referral process provided by SafeGuard. Member Responsibilities As a member, you have the responsibility to... • Identify yourself to your Selected General Dental Office as a SafeGuard member. If you fail to do so, you may be charged the dentist’s usual and customary fees instead of the applicable co-payment, if any. • Treat the dentist and his or her office staff with respect and courtesy and cooperate with the prescribed course of treatment. If you continually refuse a prescribed course of treatment, your Selected General Dentist or Specialist has the right to refuse to treat you. SafeGuard will facilitate second opinions SG-INDIV-EOC 14 CA 12/07 8/08 and will permit you to change your Selected General Dental Office; however, SafeGuard will not interfere with the dentist-patient relationship and cannot require a particular dentist to perform particular services. • Keep scheduled appointments or contact the dental office twenty-four (24) hours in advance to cancel an appointment. If you do not, you may be charged a missed appointment fee. • Make co-payments at the time of service. If you do not, the dentist may collect those co-payments from you at subsequent appointments and in accordance with their policies and procedures. • Notify SafeGuard of changes in family status. If you do not, SafeGuard will be unable to authorize dental care for you and/or your family members. Language Assistance As a SafeGuard member you have a right to free language assistance services, including interpretation and translation services. SafeGuard collects and maintains your language preferences, race, and ethnicity so that we can communicate more effectively with our members. If you require spoken or written language assistance or would like to inform SafeGuard of your preferred language, please contact us at (800) 880-1800. Como miembro de SafeGuard usted tiene derecho a recibir servicios gratuitos de asistencia en idiomas. Esto incluye servicios de interpretación y traducción. SafeGuard recaba la información sobre sus preferencias de idioma, raza, y etnia de manera que nos podamos comunicar eficazmente con nuestros afiliados. Si necesita asistencia verbal o escrita en su idioma o quiere informarle a SafeGuard sobre su idioma de preferencia, comuníquese con nosotros al (800) 880-1800. SG-INDIV-EOC 15 CA 12/07 8/08 The following definitions are used in this Evidence of Coverage. Arbitration A non-court proceeding which is used to solve legal disputes. It is usually held before an attorney or judge who weighs the evidence and renders a binding decision, which has the force of law. Arbitration is an efficient alternative to a trial court proceeding for resolving legal disputes. Co-payment The amount listed on the Schedule of Benefits for covered services that the member is required to pay at the time of treatment. Dental Records A single complete record kept at the site of your dental care. Dental records refers to diagnostic aids, such as intraoral and extra-oral radiographs, written treatment records including, but not limited to, progress notes, dental or periodontal chartings, treatment plans, specialty referrals, consultation reports or other written material relating to an individual’s medical and dental history, diagnosis, condition, treatment and/or evaluation. Dependent Eligible family members of a subscriber who is enrolled in SafeGuard. (See Dependent Coverage). Emergency Dental Services Dental services rendered for the relief of acute pain, bleeding, infection, fever, or for conditions that may result in disability or death, and where delay of treatment would be medically unadvisable. Medically Necessary Covered services that are necessary and meet with professionally recognized standards of practice. The fact that a dentist may prescribe, order, recommend or approve a service or material does not, in itself, make it medically necessary, or make it a covered service and material even though it is not listed in this Policy or the Schedule of Benefits as an exclusion. Member An individual enrolled in the SafeGuard dental plan. Plan Coverage for specified dental care services purchased by an Organization for its members for a fixed, periodic payment made in advance of treatment. Such plans often include the use of fixed co-payments to clarify the financial obligation of covered dental care, and are subject to Exclusions and Limitations. SG-INDIV-EOC 16 CA 12/07 8/08 Prepayment Fee The monthly fee paid to SafeGuard by your Organization. The prepayment fee is not the same as a co-payment. Selected General Dentist A SafeGuard contracting dentist who agrees in writing to provide dental services under special terms, conditions and financial reimbursement arrangements with SafeGuard. Service Area The Service Area is the geographical area in which SafeGuard has a panel of Selected General Dentists and specialists who have agreed to provide care to SafeGuard members. Subscriber The person, usually the employee, who represents the family unit in relation to the dental benefit program. Also known as: certificate holder, enrollee. Termination of Benefits A member’s loss of program eligibility and disenrollment from the plan. Reason for termination of benefits are detailed within this document. SG-INDIV-EOC 17 CA 12/07 8/08 SAFEGUARD DENTAL & VISION HIPAA NOTICE OF PRIVACY PRACTICES FOR PERSONAL HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Dear SafeGuard Customer: This is your Health Information Privacy Notice from SafeGuard Health Plans, Inc. and/or SafeHealth Life Insurance Company doing business as SafeGuard Dental & Vision (“SafeGuard”), part of the MetLife, Inc. family of companies. Please read it carefully. You have received this notice because of your dental and/or vision coverage with us (the “Plan”). SafeGuard and each member of the SafeGuard family of companies (an “Affiliate”) strongly believe in protecting the confidentiality and security of information we collect about you. This notice refers to SafeGuard by using the terms “us,” “we,” or “our.” This notice describes how we protect the personal health information we have about you which relates to your SafeGuard Plan coverage (“Personal Health Information”), and how we may use and disclose this information. Personal Health Information includes individually identifiable information which relates to your past, present or future health, treatment or payment for health care services. This notice also describes your rights with respect to the Personal Health Information and how you can exercise those rights. We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act (“HIPAA”). For additional information regarding our HIPAA Medical Information Privacy Policy or our general privacy policies, please see the privacy notices contained at our website, www.safeguard.net. You may submit questions to us there or you may write to us directly at MetLife/SafeGuard, Institutional Business HIPAA Privacy Office, P.O. Box 6896, Bridgewater, NJ 08807-6896. We are required by law to: • maintain the privacy of your Personal Health Information; • provide you this notice of our legal duties and privacy practices with respect to your Personal Health Information; and •follow the terms of this notice. We protect your Personal Health Information from inappropriate use or disclosure. Our employees, and those of companies that help us service your SafeGuard Plan, are required to comply with our requirements that protect the confidentiality of Personal Health Information. They may look at your Personal 2/09 Health Information only when there is an appropriate reason to do so, such as to administer our products or services. We will not disclose your Personal Health Information to any other company for their use in marketing their products to you. However, as described below, we will use and disclose Personal Health Information about you for business purposes relating to your SafeGuard Plan coverage. The main reasons for which we may use and may disclose your Personal Health Information are to evaluate and process any requests for coverage and claims for benefits you may make, or in connection with other health-related benefits or services that may be of interest to you. The following describe these and other uses and disclosures, together with some examples. • For Payment: We may use and disclose Personal Health Information to pay for benefits under your SafeGuard Plan coverage. For example, we may review Personal Health Information contained on claims to reimburse providers for services rendered. We may also disclose Personal Health Information to other insurance carriers to coordinate benefits with respect to a particular claim. Additionally, we may disclose Personal Health Information to a health plan or an administrator of an employee welfare benefit plan for various payment-related functions, such as eligibility determination, audit and review, or to assist you with your inquiries or disputes. • For Health Care Operations: We may also use and disclose Personal Health Information for our insurance operations. These purposes include evaluating a request for SafeGuard Plan products or services, administering those products or services, and processing transactions requested by you. We may also disclose Personal Health Information to Affiliates, and to business associates outside of the SafeGuard family of companies, if they need to receive Personal Health Information to provide a service to us and will agree to abide by specific HIPAA rules relating to the protection of Personal Health Information. Examples of business associates are: billing companies, data processing companies, or companies that provide general administrative services. Personal Health Information may be disclosed to reinsurers for underwriting, audit or claim review reasons. Personal Health Information may also be disclosed as part of a potential merger or acquisition involving our business in order to make an informed business decision regarding any such prospective transaction. • Where Required by Law or for Public Health Activities: We disclose Personal Health Information when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases, or providing Personal Health Information to a governmental agency or regulator with health care oversight responsibilities. We may also release Personal Health 2/09 Information to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death. • To Avert a Serious Threat to Health or Safety: We may disclose Personal Health Information to avert a serious threat to someone’s health or safety. We may also disclose Personal Health Information to federal, state or local agencies engaged in disaster relief, as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations. • For Health-Related Benefits or Services: We may use Personal Health Information to provide you with information about benefits available to you under your current SafeGuard Plan coverage or policy and, in limited situations, about health-related products or services that may be of interest to you. • For Law Enforcement or Specific Government Functions: We may disclose Personal Health Information in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose Personal Health Information about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law. • When Requested as Part of a Regulatory or Legal Proceeding: If you or your estate are involved in a lawsuit or a dispute, we may disclose Personal Health Information about you in response to a court or administrative order. We may also disclose Personal Health Information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the Personal Health Information requested. We may disclose Personal Health Information to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination. • Other Uses of Personal Health Information: Other uses and disclosures of Personal Health Information not covered by this notice and permitted by the laws that apply to us will be made only with your written authorization or that of your legal representative. If we are authorized to use or disclose Personal Health Information about you, you or your legally authorized representative may revoke that authorization, in writing, at any time, except to the extent that we have taken action relying on the authorization. You should understand that we will not be able to take back any disclosures we have already made with authorization. YOUR RIGHTS REGARDING PERSONAL HEALTH INFORMATION WE MAINTAIN ABOUT YOU The following are your various rights as a consumer under HIPAA concerning your Personal Health Information. Should you have questions about a specific right, please write to us at the location listed in our discussion of that right. 2/09 • Right to Inspect and Copy Your Personal Health Information: In most cases, you have the right to inspect and obtain a copy of the Personal Health Information that we maintain about you. To inspect and copy Personal Health Information, you must submit your request in writing to SafeGuard Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo, CA 92656. To receive a copy of your Personal Health Information, you may be charged a fee for the costs of copying, mailing or other supplies associated with your request. However, certain types of Personal Health Information will not be made available for inspection and copying. This includes Personal Health Information collected by us in connection with, or in reasonable anticipation of, any claim or legal proceeding. In very limited circumstances, we may deny your request to inspect and obtain a copy of your Personal Health Information. If we do, you may request that the denial be reviewed. The review will be conducted by an individual chosen by us who was not involved in the original decision to deny your request. We will comply with the outcome of that review. • Right to Amend Your Personal Health Information: If you believe that your Personal Health Information is incorrect or that an important part of it is missing, you have the right to ask us to amend your Personal Health Information while it is kept by or for us. You must provide your request and your reason for the request in writing, and submit it to SafeGuard Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo, CA 92656. We may deny your request if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend Personal Health Information that: • is accurate and complete; • was not created by us, unless the person or entity that created the Personal Health Information is no longer available to make the amendment; • is not part of the Personal Health Information kept by or for us; or • is not part of the Personal Health Information which you would be permitted to inspect and copy. • Right to a List of Disclosures: You have the right to request a list of the disclosures we have made of Personal Health Information about you. This list will not include disclosures made for treatment, payment, health care operations, for purposes of national security, made to law enforcement or to corrections personnel, or made pursuant to your authorization or made directly to you. To request this list, you must submit your request in writing to SafeGuard Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo, CA 92656. Your request must state the time period from which you want to receive a list of disclosures. The time period may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or 2/09 electronically). The first list you request within a 12-month period will be free. We may charge you for responding to any additional requests. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. • Right to Request Restrictions: You have the right to request a restriction or limitation on Personal Health Information we use or disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend. While we will consider your request, we are not required to agree to it. If we do agree to it, we will comply with your request. To request a restriction, you must make your request in writing to SafeGuard Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo, CA 92656. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on Personal Health Information uses or disclosures that are legally required, or which are necessary to administer our business. • Right to Request Confidential Communications: You have the right to request that we communicate with you about Personal Health Information in a certain way or at a certain location if you tell us that communication in another manner may endanger you. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to SafeGuard Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo, CA 92656 and specify how or where you wish to be contacted. We will accommodate all reasonable requests. • Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact MetLife/SafeGuard, Institutional Business HIPAA Privacy Office, P.O. Box 6896, Bridgewater, NJ 08807-6896. All complaints must be submitted in writing. You will not be penalized for filing a complaint. If you have questions as to how to file a complaint, please contact us at (908) 253-2706. ADDITIONAL INFORMATION Changes to This Notice: We reserve the right to change the terms of this notice at any time. We reserve the right to make the revised or changed notice effective for Personal Health Information we already have about you, as well as any Personal Health Information we receive in the future. The effective date of this notice and any revised or changed notice may be found on the last page, at the bottom right-hand corner of the notice. You will receive a copy of any revised 2/09 notice from SafeGuard by mail or by e-mail, but only if e-mail delivery is offered by SafeGuard and you agree to such delivery. Further Information: You may have additional rights under other applicable laws. For additional information regarding our HIPAA Medical Information Privacy Policy or our general privacy policies, please contact us at (908) 253-2706 or write to us at MetLife/SafeGuard, Institutional Business HIPAA Privacy Office, P.O. Box 6896, Bridgewater, NJ 08807-6896 © Metropolitan Life Insurance Company, New York, NY Effective - (02012008) 000685723/3296-CA-DAIS-CDT9KIT-1 The Schedule of Benefits and the Exclusions and Limitations contained within this enrollment kit are provided to give you the details of your benefit plan. Also included is your Evidence of Coverage, which provides further information regarding plan benefits. Benefits provided by SafeGuard Health Plans, Inc. SafeGuard®is a registered trademark of SafeGuard Health Enterprises, Inc. SmileSaversm is a registered servicemark of SafeGuard Health Enterprises, Inc. SM-DHMO-C
