Share of Cost, The risk of esophageal cancer among patients who suffer from gastroesophageal reflux disease (GERD) is not as high as many may think, according to new research from University of Michigan gastroenterologists. GERD is considered a relative risk for developing esophageal adenocarcinoma, but the absolute risk is not known, says Joel Rubenstein, M.D., M.Sc.

Share of Cost, The risk of esophageal cancer among patients who suffer from gastroesophageal reflux disease (GERD) is not as high as many may think, according to new research from University of Michigan gastroenterologists. GERD is considered a relative risk for developing esophageal adenocarcinoma, but the absolute risk is not known, says Joel Rubenstein, M.D., M.Sc.

a) Each Member must use a Participating Provider in order to receive services. The Plan does not assign Members to Participating Providers and Member is free to select and receive Dental Care Services from any Participating Provider. Participating Providers for Member’s geographic area may be located using Plan’s website or by telephoning the Plan at 1-888-NDC-ENROLL (1-888-632-3676). The Plan maintains an extensive network of general dentists and specialists. In most geographic areas there are specialist dentists in reasonable proximity to where Members reside. In some more rural areas, however, some specialties may not be available. Should the need arise, Members should call the Plan or consult the Plan’s website to determine where a particular specialty may be found in the Member’s area.

b) The Plan does not require notification from the Member if Member wants to change from one Participating Provider to a different Participating Provider. These rules of selection and freedom to change Participating Providers apply both to general dentists and to specialists. Member shall be solely responsible for any charges for any dental treatment received from a Non-Participating Provider under any circumstances or for any reason.

c) Unless the Member or the Plan requests otherwise, a Participating Provider withdrawing or being terminated from the Plan is obligated to provide, following the date of his or her termination from the Plan, Dental Care Services to a Member in the course of commenced but uncompleted treatment by the Provider on the date of such withdrawal or termination from the Plan at the discounted fees to which the Member is entitled under this Agreement until the course of treatment has been completed.

d) Should the Plan cease to be in business, the Participating Provider is obligated to continue to provide Dental Care Services to Members at the discounted fees to which the Member is entitled under this Agreement until the Member’s paid annual membership terminates.

e) The Plan will post on its website the names of Participating Providers who (1) have given notice to Plan that they intend to withdraw from the Plan’s provider network; (2) are being terminated from the Plan; or (3) become unable to perform as a Participating Provider This notice under normal circumstances will be posted no less than sixty (60) days before the Provider will cease to be a Provider in the Plan, although in instances where the Provider is being terminated for reasons of cause or otherwise becomes unable to perform as a Provider, the website notice may be posted in fewer days. Therefore, Members are encouraged to consult the Plan’s website to determine the status of a particular Participating Provider, or they may call the Plan’s toll-free number and speak with a Member Services Representative (1-888-632-3676).

You must be a California resident to enroll in this plan. There is a six-month waiting period for minor services and no coverage for major services. $25 calendar-year deductible per member with $500 calendar year benefit maximum per member. This is a brief overview of the exclusions and limitations of the policy. Please review the Evidence of Coverage and Health Service Agreement before purchasing this plan.

Introduction to the Value Smile PPO:  Blue Shield’s dental plans are administered by a Dental Plan Administrator (DPA) which is a dental care service plan and which contracts with Blue Shield to underwrite and administer the delivery of dental services through a network of Participating Dentists.

Before Obtaining Dental Care Services: You are responsible for assuring that the Dentist you choose is a Participating Dentist. Note: A Participating Dentist’s status may change. It is your obligation to verify whether the Dentist you choose is currently a Participating Dentist in case there have been any changes to the list of Participating Dentists. A list of Participating Dentists located in your area, can be obtained by contacting a Dental Plan Administrator at 1- 888-679-8928. You may also access a list of Participating Dentists through Blue Shield Life’s internet site located at http://www.blueshieldca.com.

Choice of Dentists: The Value Smile PPO is specifically designed for you to use Participating Dentists. Participating Dentists agree to accept a Dental Plan Administrator’s payment, plus your payment of any applicable Deductible and Copayment, as payment in full for Covered Services. This is not true of Non-Participating Dentists. Participating Dentists submit claims for payment after Dental Care Services have been rendered. Payments for these claims go directly to the Participating Dentist. You or your Non- Participating Dentists submit claims for reimbursement after services have been rendered. If you receive Dental Care Services from Non-Participating Dentists, you have the option of having payments sent directly to the Non-Participating Dentist or sent directly to you. A Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim. Participating Dentists do not receive financial incentives or bonuses from Blue Shield Life.

Dental Necessity Exclusion All Services must be of Dental Necessity. The fact that a Dentist or other provider may prescribe, order, recommend, or approve a service does not, in itself, make it of Dental Necessity, even though it is not specifically listed as an exclusion or limitation. The Plan may limit or exclude benefits for services that are not of Dental Necessity.

Calendar Year Deductible: There is a Calendar Year Deductible of $25 that applies to all Covered Services and supplies furnished by Participating and Non-Participating Dentists 1. It is the amount that you must pay out of pocket before benefits will be provided for Covered Services. This Deductible applies each Calendar Year. This Deductible applies separately to each covered Insured, each Calendar Year. Except as noted, the Calendar Year Deductible of $25 applies to all covered Services and supplies furnished by Participating and Non-Participating Dentists. It is the amount that you must pay out of pocket before benefits will be provided for Covered Services. This Deductible applies each Calendar Year. The Calendar Year Deductible does not apply to those dental Services considered by Blue Shield Life to be diagnostic or preventive. Services that are considered diagnostic or preventive by Blue Shield Life are listed in the section entitled Summary of Benefits and Insured’s Copayments.

Calendar Year Maximum Payment: Your Plan pays up to a maximum of $500 each Calendar Year for Covered Services and supplies provided by any combination of Participating and Non-Participating Dentists.

You are reviewing the Dental Insurance PPO Value Plan $500 Max Underwritten by Blue Shield of California. This dental plan offers individual and family dental services to eligible residents in the household, including their lawful spouse, domestic partner and dependent children subject to the guidelines noted in the policy and issued by the company. Dependents may include all unmarried children under the age of 26 who are chiefly dependent on the subscriber for support and maintenance. This plan is for members age 64 and under if you are 65 and over please select another plan. The dental insurance plan offers your choice of network dentist and you can change your dentist anytime by notifying the company.

Your savings are in place when you visit your dentist so you just show up for your dental appointment and make your co-payment – what could be easier? The dentists must meet the Plan’s standard of quality and service. All have agreed to provide dental care at a low cost available only to its members. There is no waiting period for your diagnostic and preventive services to start. Just a reminder your mail-in application must be received by the company on or before the 20th of the month prior to the following month’s coverage effective date. Review the sample schedule below and see how easy it is for you or your entire family to enjoy these quality dental services.  You are reviewing the Dental Insurance PPO Value Plan $500 Max Underwritten by Blue Shield of California. This dental plan offers individual and family dental services to eligible residents in the household, including their lawful spouse, domestic partner and dependent children subject to the guidelines noted in the policy and issued by the company. Dependents may include all unmarried children under the age of 26 who are chiefly dependent on the subscriber for support and maintenance. This plan is for members age 64 and under if you are 65 and over please select another plan. The dental insurance plan offers your choice of network dentist and you can change your dentist anytime by notifying the company. Your savings are in place when you visit your dentist so you just show up for your dental appointment and make your co-payment – what could be easier?

The dentists must meet the Plan’s standard of quality and service. All have agreed to provide dental care at a low cost available only to its members. There is no waiting period for your diagnostic and preventive services to start. Just a reminder your mail-in application must be received by the company on or before the 20th of the month prior to the following month’s coverage effective date. Review the sample schedule below and see how easy it is for you or your entire family to enjoy these quality dental services.

Reviewing the MultiFlex Dental Insurance Classic Plan Max 2000 Underwritten by Nationwide Life Insurance Company. This dental insurance plan offers individual and family dental benefits for members age 64 and younger. If you are 65 years of age or older please select another dental plan. A family membership covers the head of household including spouse (if not legally separated or divorced from you); unwed child from the moment of birth, until the child attains age 19; and unwed child who is a student may be covered until age 26 provided such child is a full-time student and more than 50% dependent on you for support and maintenance and proof of the child’s enrollment as a full-time student has been submitted.

The dental insurance plan offers you a free choice of dentists and you can change your dentist anytime by notifying the company. Your savings are in place when you visit your dentist so you just show up for your dental appointment and make your co-payment – what could be easier? You can enroll anytime you prefer… Just a reminder that your online request must be processed on or before the 5th of the month for coverage to be effective the same month. Please review the dental benefit co-payments below and see how easy it is for you or your entire family to enjoy these quality dental benefits

Applicant’s Statements and Agreements:  1. I understand that the effective date of the policy will be the date recorded in the Policy Schedule of Benefits by the Company.  2. I understand the policy I am applying for contains different Waiting Periods for certain benefits listed in the Policy Schedule of Benefits. This means that no benefits are payable during the listed Waiting Period. The Waiting Period begins on the effective date of coverage.  3. I understand that dependent children, if any, will be covered until the end of the month following their 19th birthday (24th if full-time students).  4. I understand that: (a) Starmount Life Insurance Company is not bound by any statement made by me, the applicant, or any associate/agent of Starmount Life Insurance Company unless written herein. (b) The associate/agent cannot change the provisions of the policy or waive any of its provisions either orally or in writing. (c) The policy together with this application, endorsements, benefit agreements and riders, if any, is the entire contract of insurance. (d) No change to the policy will be valid until approved by Our president and secretary, and noted in or attached to the policy.

5. I acknowledge receipt of, if applicable:Outline of Coverage.

Authorization to Obtain Information: I authorize the following to give information (defined below) to Starmount Life Insurance Company or any person or group acting on their part: any medical professional, any medical care institution, insurer, reinsurer, government agency, or employer. “Information” means facts of a medical nature in regard to my physical or mental condition, employment, or other insurance coverage. I understand that this information will be used by Starmount Life Insurance Company to determine eligibility for insurance and may be used to evaluate a claim for benefits during the time it is valid. I agree that this authorization is valid for 30 months from the date signed. I know that I have a right to receive a copy of this authorization upon request. I agree that a copy of this authorization is as valid as the original.

Please Note : California law prohibits an HIV test from being required, DISCLOSED or used by health insurance companies as a condition of obtaining health insurance cove rage .

I understand that the premium amount listed on this application represents the premium amount that either my employer will remit to Starmount Life Insurance Company on my behalf, or I will remit directly to them. I further understand that this amount, because of my employer’s billing/payroll practices, may differ from the amount being deducted from my paycheck or the premium amount quoted to me by my associate/agent. I also understand that if I am receiving any Medicaid benefits, the purchase of this coverage may not be necessary. If I am applying to replace existing coverage with this policy, I acknowledge that the policies may have different benefits and that I should make a comparison to personally determine which is best for me. I understand and agree that I am terminating my current policy and its benefits for the benefits provided in the Starmount Life Insurance Company Policy. I have read, or had read to me, the completed application, and I realize policy issuance is based upon statements and answers provided herein, and they are complete and true to the best of my knowledge and belief. I understand that any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Reviewing the AlwaysCare One Plus PPO Dental Value Plan $1000 Max Benefit underwritten by Starmount Life Insurance Company for Adults (ages 19 to 64). This dental plan offers individual and family dental benefits. Family coverage includes the insured; the insured’s spouse; including and dependent, unmarried children to age 26. One-parent family coverage includes the insured and dependent, unmarried children to age 26. Newborn children are automatically covered from the moment of birth. The dental insurance plan offers you a free choice of network dentists.

Your savings are in place when you visit your dentist so you just show up for your dental appointment and make your co-payment – what could be easier? There is no waiting period for your preventive services to start. Please review the dental benefits paid by the insurance company below and see how easy it is for you or your entire family to enjoy these quality dental services. Just a reminder your mail-in application and payment must be received on or before the 20th of the month prior to the following month’s coverage effective date.

Madison Nation Life Insurance Company Offers Dental Insurance With ShareOfCost.com — Consider the Indemnity Value Dental Insurance Plan $500 Maximum Benefit Underwritten by Madison National Life Insurance Company, Inc. This dental insurance plan offers dental benefits for individuals and families. A family membership covers the applicant, spouse, and your dependent children ages 25 or younger. The dental insurance plan offers your choice of dentist and you can change your dentist anytime by notifying the company. Your savings are in place when you visit your dentist so you just show up for your dental appointment and make your co-payment – what could be easier? Dental health care and orthodontic coverage is included for dependent children.

There is no waiting period for your preventive services to start. Please review the dental benefit co-payments below and see how easy it is for you or your entire family to enjoy these quality dental services. Just a reminder your online request must be processed on or before the 20th of the month prior to the following month’s coverage effective date.

The orthodontic benefit covers: consultation, all necessary appliances, banding, and monthly office visits for 24 months. Specific co-payment levels have also been set for start-up and retention services.  Orthodontic treatment must be provided by a Panel Orthodontist. A referral must be submitted by the assigned general dentist and approved by the Plan. Rates and coverage’s subject to change without notification.

LIMITATIONS AND EXCLUSION:

ARBITRATION: The Plan uses binding arbitration to resolve any and all disputes between the Plan and group or member, including, but not limited to, allegations against Plan of medical malpractice (that is an to whether any dental services rendered under the Plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered) and other disputes relating to the delivery of services under the Plan.

Plan, group and member each understand and expressly agree that by entering into the Plan services group subscriber agreement or enrolling in Plan and agreeing to be bound by the Plan subscriber agreement. Plan, group and member are each voluntarily giving up their constitutional right to have all such disputes decided in a court of law before a jury and instead are accepting the is of binding arbitration. Group and member further contracting provider including but not limited to claims against a Plan contracting provider for medical malpractice are not governed by the Plan subscriber agreement.

However Plan, group and member each expressly agree that the existence of any disputes between group or member and a Plan contracting provider, including but not limited to claims by groups or member against a Plan contracting provider for medical malpractice shall in no way affect the obligation to submit to binding arbitration all disputes between group or member and Plan.

LIMITATIONS: Dentures or partials once every five years and then only when dentures cannot be made serviceable; cleanings once every six months; relines not more than twice per year; full mouth x-rays once every two years; all family members must be assigned to the same dental office; orthodontic treatment must be provided by a member of the Plan Orthodontic Panel.

EXCLUSIONS: Oral surgery requiring the setting of fractures or dislocations; treatment of malignancies, cysts or neoplasms; dispensing of drugs; teeth extracted for orthodontic purposes; cosmetic dentistry; treatment of temporomandibular joint syndrome (tmj); treatment by a specialist.

DISCLOSURE: An application is a request for coverage which if approved by the Plan would then become the enrollment form and would be used to issue an identification card and a Disclosure Form. Upon acceptance of the application by the Plan, your benefits will become effective on the first of the next month. Detailed limitations and exclusions, coverage benefits, co-payments, as well as other services offered, are given in full in the Disclosure Form provided when coverage becomes effective. The Insurance Company always reserves the right to make the final determination with respect to all aspects of this Dental Program.

Regarding the PacifiCare Dental Insurance Plan (Region 1). This dental plan offers individual and family dental benefits. A family membership covers the head of household including spouse, your children 19 years of age or younger and your children up to age 23 if attending school full time. Your online request must be processed on or before the 20th of the month prior to the coverage effective date. This dental plan starts on the 1st of next month if you have enrolled by the 20th of this month. Be sure to leave yourself enough time to mail in your application.

There are no deductibles and no yearly limits on benefits, and there are no claim forms to fill out. Your savings are in place when you visit your dentist. You just show up for your dental appointment and make your co-payment – what could be easier? The dentists must meet the Plan’s standard of quality and service. All have agreed to provide dental care at the low co-payments available only to members. Review the dental benefit co-payments below and see how easy it is for you or your entire family to enjoy these quality dental services.

Dental Health Services Dental Plan Limitations and Exclusion: Summary of Dental exclusions: This is a very brief overview. Please refer to the evidence of coverage before purchasing this dental plan.  The following services are not covered by this dental plan:
A. Services that are not consistent with professionally recognized standards of practice.
B. Services related to implants or attachments to implants.
C. Cosmetic services, for appearance only, unless specifically listed.
D. Myofunctional therapy-procedures for training, treating or developing muscles in and around the jaw or mouth including T.M.J. and related diseases, except for occlusal guard.
E. Treatment for malignancies, neoplasms (tumors) and cysts as well as hereditary, congenital and/or developmental malformations.
F. Dispensing of drugs not normally supplied in a dental office.
G. Hospitalization charges, dental procedures or services rendered while patient is hospitalized.
H. Procedures, appliances or restorations (other than fillings) that are necessary for full mouth rehabilitation, to increase arch vertical dimension, or crown/bridgework requiring more than 10 crowns/pontics. Replacement or stabilization of tooth structure lost through attrition, abrasion or erosion.

Procedures performed by a prosthodontist.
I. Fixed bridges for patients under the age of sixteen, in the presence of nonsupportive periodontal tissue, when edentulous spaces are bilateral in the same arch, when replacement of more than four teeth in an arch, replacement of missing third molars, or when the prognosis is poor.
J. General anesthesia, including intravenous and inhalation sedation.
K. Dental procedures that cannot be performed in the dental office due to the general health and/or physical limitations of the member.
L. Expenses incurred for dental procedures initiated prior to member’s eligibility with Dental Health Services, or after termination of eligibility.
M. Services that are reimbursed by a third party (such as the medical portion of an insurance/health plan or any other third party indemnification).
N. Extractions of non-pathologic, asymptomatic teeth, including extractions and/or surgical procedures for orthodontic reasons.
O. Setting of a fracture or dislocation, surgical procedures related to cleft palate, micrognathia or macrognathia, and surgical grafting procedures.
P. Coordination of benefits with another prepaid managed care dental plan.
Q. Orthodontic treatment of a case in progress and/or retreatment of orthodontic cases.
R. Cephalometric x-rays, tracings, photographs and orthodontic study models.
S. Replacement of lost or broken orthodontic appliances.
T. Changes in orthodontic treatment necessitated by an accident of any kind.
U. Malocclusions so severe or mutilated which are not amenable to ideal orthodontic therapy.
V. Services not specifically covered on the Schedule of Covered Services and Copayments.

Dental limitations: Restrictions on benefits are applied to the following services
A. Treatment of dental emergencies is limited to treatment that will alleviate acute symptoms and does not cover definitive restorative treatment including, but not limited to root canal treatment and crowns.
B. Optional services: when the patient selects a plan of treatment that is considered optional or unnecessary by the attending dentist, the additional cost is the responsibility of the patient.
C. Routine teeth cleaning (prophylaxis) is limited to once every six months and full mouth x-rays are limited to one set every three years if needed.
D. Sealants are only a benefit for permanent posterior teeth of children under the age of eighteen.
E. Covered specialist referrals must be pre-approved by Dental Health Services.
F. Periodontal surgical procedures are limited to four quadrants every two years.
G. There are additional charges for precious/noble metals (gold).
H. Replacement will be made of any existing appliance (denture, etc.) only if it is unsatisfactory and cannot be made satisfactory. Prosthetic appliances will be replaced only after five years have elapsed from the time of delivery. Lost or stolen removable appliances are the responsibility of the enrollee.
I. Relines are limited to once per twelve months, per appliance.
J. Single unit inlays and crowns are a benefit as provided above only when the teeth cannot be adequately restored with other restorative materials.
K. The maximum benefit for all contracted specialty care, excluding orthodontics, is $1,000 per member, per contract year.

Orthodontic exclusions: The following services are not covered by this dental plan
A. Retreatment of orthodontic cases.
B. Treatment of a case in progress at inception of eligibility.
C. Surgical procedures (including extraction of teeth) incidental orthodontic treatment.
D. Surgical procedures related to cleft palate, micrognathia or macrognathia.
E. Treatment related to temporomandibular joint (TMJ) disturbances and/or hormonal imbalances.
F. Any dental procedure considered within the field of general dentistry,including but not limited to: myofunctional therapy; general anesthetics, including intravenous and inhalation sedation; dental services of any nature performed in a hospital.
G. Orthodontic treatment of a case in progress and/or retreatment of orthodontic cases
H. Cephalometric x-rays, tracings, photographs and orthodontic study models.
I. Replacement of lost or broken orthodontic appliances
J. Changes in treatment necessitated by an accident of any kind.
K. Services which are compensable under worker’s compensation or employer liability laws.
L. Malocclusions so severe or mutilated they are not amenable to ideal orthodontic therapy.

Orthodontic limitations: The following are subject to additional charges
A. Full banded treatments are based on a 24-month standard treatment plan. Additional treatment, or treatment that extends beyond that time may be subject to additional charges. If the contract between the enrollee and Dental Health Services is terminated, service is subject to a pro-rated fee based on current market value for the balance of orthodontic treatment. If the member should terminate coverage, they are no longer eligible for the enrollee orthodontic rate. Should the contract between Dental Health Services and the orthodontist terminate, any Dental Health Services members in treatment would not be subject to proration. Please call your Member Service Specialist at 800.63.SMILE for a referral to the nearest participating orthodontist.

Health plan benefits and coverage matrix: THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Deductibles: None
Lifetime maximums: None.
Professional services – exam & preventive services: No charge for most services.
Full mouth x-rays limited to every three years. Prophylaxis (cleanings) limited to every six months. Sealants limited to permanent teeth to age 18.
Professional services – restorative, crowns, endodontics and oral surgery services: Copayments for fillings, caps, root canals and extractions vary by procedure in the enclosed Schedule.
Professional services – periodontic services: Copayments for gum treatments vary by procedure in the enclosed Schedule. Surgical procedures are limited to four quads every two years.
Professional services – dentures and partial dentures: Copayments vary by procedure and appear in the enclosed Schedule. Replacements limited to every five years. Relines limited to every 12 months.
Professional services – specialty services: Copayments vary by procedure and appear in the enclosed Schedule of Covered Services and Copayments. There is a $1,000 maximum benefit per member, per contract year, excluding orthodontics. See Services when performed by a Dental Health Services specialist.
Outpatient office visits: $4 per visit
Hospitalization services: Not covered
Prescription drug coverage: Not covered
Emergency health services: Not covered
Ambulance services: Not covered
Durable medical equipment: Not covered
Mental health services: Not covered
Chemical dependency services: Not covered
Home health services: Not covered
This dental plan does not provide general anesthesia. Members requiring

Dental Health Services, Share of Cost California Dental Plan Review — The Dental Health Services Super SmartSmile HMO Dental Plan. As the subscriber, you may enroll yourself, your spouse (unless legally separated) or your domestic partner, and/or unmarried dependent children who are under 19 years of age. Children 19 years of age and over are eligible if: The child is unmarried and a full-time student solely dependent upon subscriber for support, and is under 23 years of age; or the child is and continues to be both (1) incapable of self-sustaining employment by reason of a mental disability, including but not limited to, mental illness or a physical disability or a combination of those disabilities and (2) chiefly dependent upon the subscriber or member for support and maintenance. There are no deductibles and no yearly limits on most services, and there are no claim forms to fill out. Your savings are in place when you visit network dentist. You just show up for your dental appointment and make your copayment – what could be easier? The dentists must meet the Plan’s standard of quality and service.

All have agreed to provide dental care at a low cost available only to its members. There is no waiting period for your dental services to begin, many pre-existing dental conditions are covered and best of all, the dental plan services start the first day of next month if the company receives your mail-in application by the 10th of this month. Review the sample schedule below and see how easy it is for you or your entire family to enjoy these quality dental services.

Here are some of the disclosures to consider when purchasing the Liberty Dental Plan of California: Liberty Dental Plan will activate your benefits on the first of next month if your mail-in application and payment is received in their office by the 20th of this month. Subject to cancellation as provided under this Program, enrollment of Eligible Members and Eligible Dependents* is for a minimum period of one year. Twelve Consecutive Months. All Members and Dependents must use a Dentist within the LIBERTY Dental Plan Network of California Dentists.

All services and benefits under our Dental Plans are covered only if provided by a contracted LIBERTY Dental Plan participating Primary Care Dentist or if referred to a Dental Specialist by LIBERTY Dental Plan. The only time you may receive care outside of the network is for true emergency dental services necessary when you are out-of-the area or cannot contact your Primary Care Dentist or LIBERTY Dental Plan. LIBERTY Dental Plan will reimburse you for true emergency dental treatment expenses up to a maximum of $75.00 per year, less applicable co-payments.

* Base metal is the benefit. Noble metal, high noble metal, titanium alloy and titanium, if used, will be charged to the member at the additional lab cost of the noble metal, high noble metal, titanium alloy or titanium. Exception: Implants and all services associated with implants are listed at the actual member co-payment amount. No additional fee is allowable for noble metal, high noble metal, titanium alloy or titanium for implants and procedures associated with implants.

Resin, porcelain and any resin to metal or porcelain to metal crowns and pontics are a benefit on anterior (teeth numbers 6-11, 22-27), first bicuspid (teeth numbers 5, 12, 21, and 28) and second bicuspid (teeth numbers 4, 13, 20, and 29) teeth only. The member will be charged the additional lab cost to add resin or porcelain to all molar (teeth numbers 1-3, 14-19, 30-32) crowns and pontics. Exception: Implants and all services associated with implants are listed at the actual member co-payment amount. No additional fee is allowable for resin or porcelain for procedures associated with implants.

The maximum amount chargeable to the member to upgrade to resin or porcelain on molar teeth (teeth number 1-3, 14-19, 30-32) and/or upgrade to noble metal, high noble metal, titanium alloy or titanium is $250.00

** Amalgam fillings are benefits on molar and bicuspid teeth (teeth numbers 1-5, 12-21, 28-32). If the member upgrades to a resin-based composite filling, they will pay the additional co-payment listed for these procedures (D2391-D2394).

*** Covered benefit only when in conjunction with covered oral surgery and pedodontic procedures when dispensed in a dental office by a practitioner acting within the scope of his/her licensure; and when warranted by documented conditions that local anesthetic is contraindicated. General anesthesia, as used for dental pain control, means the elimination of all sensations accompanied by a state of unconsciousness. Patient apprehension and/or nervousness are not of themselves sufficient justification for deep sedation/general anesthesia or intravenous conscious sedation/analgesia.

LIBERTY Dental Plan will arrange for you to receive services from a Contracted Dental Specialist if the necessary treatment is outside the scope of General Dentistry. Your General Dentist will initiate the referral process with LIBERTY Dental Plan. The proper referral process must be utilized for specialty services to be covered under your plan. X-rays for diagnostic purposes are benefits in the General Dentist’s office only.

Limitations

(1) Prophylaxis are covered once every six consecutive months. (2) Full Mouth X-rays are limited to once every 36 consecutive months. (3) Fluoride Treatments are covered once every 6 consecutive months, up to the 18th birth date. (4) Sealants are covered only on the first and second permanent molars and up to the 14th birth date. (5) Crowns, Jackets, Inlays and Onlays are benefits on the same tooth only once every five years, and consistent with professionally recognized standards of dental practice. (6) Replacement of existing Full and Partial Dentures are covered once per arch every 5 years, except when they cannot be made functional through reline or repairs. (7) Denture Relines are covered twice per year, and only when consistent with professionally recognized standards of dental practice. (8) Any routine dental services performed by a Primary Care Dentist or Specialist in an inpatient/outpatient hospital setting, under certain circumstances, will be considered for coverage.

Exclusions

(1) Any procedure not specifically listed as a Covered Benefit. (2) Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures, full dentures, and orthodontic appliances. (3) Any treatment requested, or appliances made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a benefit. (4) Procedures considered experimental, treatment involving implants or pharmacological regimens (See “Independent Medical Review” on page 5). (5) Oral surgery requiring the setting of bone fractures or bone dislocations. (6) Hospitalization. (7) Out-patient services. (8) Ambulance services. (9) Durable Medical Equipment. (10) Mental Health services. (11) Chemical Dependency services. (12) Home Health services. (13) General anesthesia, analgesia, intravenous/intramuscular sedation or the services of an anesthesiologist. (14) Treatment started before the member was eligible, or after the member was no longer eligible. (15) Procedures, appliances, or restorations to correct congenital, developmental or medically induced dental disorder, including but not limited to: myofunctional(e.g. speech therapy), myoskeletal, or temporomandibular joint dysfunctions (e.g. adjustments/corrections to the facial bones) unless otherwise covered as an orthodontic benefit. (16) Procedures which are determined not to be dentally necessary consistent with professionally recognized standards of dental practice. (17) Treatment of malignancies, cysts, or neoplasms. (18) Orthodontic treatment started prior to member’s effective date of coverage. (19) Appliances needed to increase vertical dimension or restore occlusion. (20) Any services performed outside of your assigned dental office, unless expressly authorized by Liberty Dental Plan, or unless as outlined and covered in “Emergency Dental Care” section.

Orthodontic Exclusions

(1) Lost, stolen or broken appliances. (2) Extractions for orthodontic purposes, (will not be applied if extraction is consistent with professionally recognized standards of dental practice or arises in the context of an emergency dental condition). (3) Temporomandibular joint syndrome (TMJ) surgical orthodontics. (4) Myofunctional therapy. (5) Treatment of cleft palate. (6) Treatment of micrognathia. (7) Treatment of macroglossia.

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 1-888-703-6999 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 remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for 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 toll-free 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.

California Dental Network Plan Exclusions and Limitations: An Enrollment Application is a request for coverage, which, if approved by California Dental Network, becomes the enrollment form used to issue an identification card and Combined Evidence of Coverage and Disclosure Form. All benefits, limitations and exclusions are stated in full in the Combined Evidence of Coverage and Disclosure Form which is provided when coverage becomes effective. Members will have 30 days from receipt of the Combined Evidence of Coverage and Disclosure Form to cancel their enrollment and receive a full refund of their premiums if they have not utilized the Plan. You may obtain a copy of the Combined Evidence of Coverage and Disclosure Form from their Corporate Office before you enroll.

Limitations (1) Prophylaxis (cleaning) is limited to once every six months. (2) Fluoride treatment is covered once every 12 months for Members up to age 14. (3) Bitewing x-rays are limited to one series of four films every 12 months. (4) Full mouth x-rays are limited to once every 24 months. (5) Sealants are covered for Members up to the age of 14 and are limited to permanent first and second molars. (6) Periodontal treatments (subgingival curettage and root planing) are limited to one treatment per quadrant in any 12-month period. (7) Fixed bridgework will be covered only when a partial cannot satisfactorily restore the case.(8) Replacement of partial dentures is limited to once every five years. (9) Full upper and/or lower dentures are not to exceed one each in any five-year period. (10) Denture relines are limited to one per arch in any 12-month period.

Exclusions (1) General anesthesia, analgesia (nitrous oxide), intravenous sedation, or the services of an anesthesiologist. (2) Treatment of fractures or dislocations; congenital malformations; malignancies, cysts, or neoplasms; or Temporomandibular Joint Syndrome (TMJ). (3) Extractions or x-rays for orthodontic purposes. (4) Prescription drugs and over the counter drugs. (5) Any services involving implants or experimentalprocedures. (6) Any procedures performed for cosmetic, elective or aesthetic purposes. (7) Any procedure to replace or stabilize tooth structure lost by attrition, abrasion, erosion or grinding.

Not all general dentists are capable of performing each of the services listed herein and, based upon the Member’s condition, certain procedures may not be within the scope of practice or ability of a general dentist. In such cases, the general dentist will refer the Member to a California Dental Network participating dental specialist, who will give the Member a 30% discount from their regular fees during the first year of enrollment, and a 50% discount thereafter, for up to $1,000 in services per year. The ratio of premium costs to health services paid, for plan contracts with individuals and groups of 25 or fewer members, during the preceding fiscal year was 0%. * UCR means the dentist’s or specialist’s Usual, Customary & Reasonable fees. # Member is responsible for the payment shown plus the actual lab cost of gold. Orthodontists may charge Members additional fees for costs of cases over 24 months, based on the differences in UCR fees for the needed treatment periods less the UCR fees for a 24-month treatment period.

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 1-714-479-0777 or toll-free 1-877-4-DENTAL 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 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 toll-free 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.

Share of Cost Dental Plans, California Dental Network:  Here is some information on the California Dental Network HMO Dental Plan 411. This dental plan offers individual and family dental services to eligible residents in the household, including their lawful spouse and dependent children. Dependents shall also include all unmarried children under the age of 19 who are chiefly dependent on the subscriber for support and maintenance. Extension of eligibility may be made up to the age of 23 years for unmarried children who are principally dependent upon the subscriber and are registered students in regular, full-time attendance at an accredited school, college, or university (subscriber will be required to submit evidence of full-time status). There are no deductibles and no yearly limits on services, and there are no claim forms to fill out. Your savings are in place when you visit network dentist. You just show up for your dental appointment and make your co-payment – what could be easier?

The dentists must meet the Plan’s standard of quality and service. All have agreed to provide dental care at a low cost available only to its members. There is no waiting period for your dental services to begin, pre-existing dental conditions are covered. A reminder your mail-in application must be received by the company on or before the 20th of the month prior to the following month’s coverage effective date. Review the sample schedule below and see how easy it is for you or your entire family to enjoy these quality dental services.