GROUP EVIDENCE OF  
COVERAGE  
AND DISCLOSURE FORM  
LIBERTY Dental Plan of California, Inc.  
This Evidence of Coverage and Disclosure Form provides the following  
information:  
*
The advantages of your LIBERTY Dental Plan and how to use your  
benefits  
*
*
*
An evidence of coverage  
How to enroll in the plan  
Answers to your frequently asked questions  
Information required by the state of California in regards to your dental plan.  
STATE OF CALIFORNIA DEPARTMENT OF MANAGED HEALTH  
CARE (DMHC) COMPLAINT PROCEDURE  
The DMHC has established a toll-free number for you as a member to utilize  
should you have a complaint against a health care service plan. This number  
is 888-HMO-2219. As a member you may file a complaint against  
LIBERTY Dental Plan; however, you may only do so after contacting your  
plan directly to utilize its complaint resolution process.  
A member may immediately file a complaint with the California DMHC in  
the event of a dental emergency situation. In addition a member may also  
file a complaint in the event that the plan does not satisfactorily resolve the  
complaint (grievance) within thirty (30) days of filing with your health care  
service plan.  
This brochure will provide you with the information you should know about  
your Dental Plan. It explains clearly how it works and the many advantages  
LIBERTY Dental Plan provides you.  
LIBERTY Dental Plan BENEFITS ARE EASY TO USE  
Dental Benefits should be simple to use for you and your family. Our plans  
offer comprehensive dental coverage without claim forms, prohibitive  
deductibles, or restrictive annual maximums.  
The difference with LIBERTY Dental Plan: good provider selection, clear  
communication, and, most importantly, requiring the dentists to perform to  
the standards of the participating contract they signed with the plan.  
That is the difference in LIBERTY Dental Plan. We have open  
communication and provide excellent support to our panel of participating  
dentists.  
Our goal is to provide you with the comprehensive dental benefits you  
purchased. We pledge to support your choice of LIBERTY Dental Plan by  
giving you confidence through the excellent customer service you deserve.  
After all, isn’t that what it is all about?  
At LIBERTY Dental Plan, you get quality dental benefits at a very  
reasonable price.  
THE LIBERTY Dental Plan ADVANTAGES  
*
*
*
*
*
*
*
*
*
*
No Claim Forms  
No Deductibles or Maximums  
Low Out-of-Pocket Costs  
Selection of Pre-screened Dentists & Specialists  
Multi-Lingual Provider Network  
Change Dentist Selection Any Time  
Orthodontic Coverage  
Most Pre-existing Conditions Covered  
Network Dentists Provide 24-hour Access to Emergency Care  
Toll-Free Member Assistance Lines  
The hearing and speech impaired may use the California Relay Service  
toll-free telephone numbers (800) 735-2929 (TTY) or (888) 877-5378  
(TTY) to contact the department.  
This booklet includes your Evidence of Coverage and Disclosure From.  
Please keep this together with your records and your Schedule of Benefits,  
which includes the member co-payments, exclusions and limitations of the  
benefits and additional provisions of your dental plan.  
This is a summary of how your LIBERTY Dental Plan dental plan works.  
This Evidence of Coverage and Disclosure Form will assist you in properly  
understanding your dental plan.  
EOC – Group (No Dependents)  
Revised 04/11  
2
This Evidence of Coverage and Disclosure Form constitutes only a summary  
of the dental plan. The Agreement between LIBERTY Dental Plan of  
California, Inc. and the Employer must be consulted to determine the exact  
terms and conditions of coverage.  
SECOND OPINION  
At no cost to you, you may request a second dental opinion, when  
appropriate, by directly contacting Member Services either by calling the  
toll-free number (888) 703-6999 or by writing to: LIBERTY Dental Plan,  
P.O. Box 26110, Santa Ana, CA 92799-6110. Your primary care dentist  
may also request a second dental opinion on your behalf by submitting a  
Standard Specialty or Orthodontic Referral Form with appropriate x-rays.  
All requests for a second dental opinion are approved by LIBERTY Dental  
Plan within five (5) days of receipt of such request. Upon approval,  
LIBERTY Dental Plan will make the appropriate second dental opinion  
arrangements and advise the attending dentist of your concerns. You will  
then be advised of the arrangement so an appointment can be scheduled.  
Upon request, you may obtain a copy of LIBERTY Dental Plan’s policy  
description for a second dental opinion.  
YOUR DENTAL PLAN  
LIBERTY Dental Plan has been providing and administering dental benefits  
in California for over twenty-five (25) years. LIBERTY Dental Plan is in  
the on-going process of enhancing our statewide panel of participating  
dentists and specialists to accommodate the needs of our Subscribers.  
Our goal is to provide Californians with appropriate dental benefits,  
delivered by highly qualified dental professionals in a comfortable setting.  
All of LIBERTY Dental Plan’s contracted private practice dentists have  
undergone strict credentialing procedures, background checks and office  
evaluations. In addition, each LIBERTY Dental Plan participating dentist  
must adhere to strict contractual guidelines. All dentists are pre-screened  
and reviewed on a regular basis. Our Provider Relations Department  
conducts a quality assessment program which includes ongoing contract  
management to assure compliance with continuing education, accessibility  
for members, appropriate diagnosis and treatment planning. In addition, we  
conduct random surveys of member groups to evaluate their view of the  
dental plan overall. This includes both Primary Care Dentists (General  
Dentists) and Specialists. Your Primary Care Dentist will provide for all of  
your dental care needs, including referring you to a specialist should it be  
necessary.  
EOC – Group (No Dependents)  
Revised 04/11  
3
When you join LIBERTY Dental Plan, you must choose a Primary Care  
Dentist. If you desire to make a change, you may do so at any time. (Please  
note: Your request to change dentists will not be processed if you have an  
outstanding balance with your current dentist.) Simply contact our Member  
Services Department toll-free at (888) 703-6999 or submit a change request  
in writing to: LIBERTY Dental Plan, P.O. Box 26110, Santa Ana, CA  
9
2799-6110. Your requested change to a Primary Care Dentist will be in  
st  
effect on the first (1 ) day of the following month if the change is received  
by LIBERTY Dental Plan prior to the twentieth (20 ) of the current month.  
th  
NOTE: Those enrolling in plans CA80, CA90, Prestige II or Prestige III are  
not required to select a Primary Care Dentist at the point of enrollment. To  
access care under one of these plans, simply contact a LIBERTY Dental Plan  
provider who is contracted to provide services under your selected plan for  
an appointment. The Primary Care Dentist will then contact LIBERTY  
Dental Plan to verify your eligibility.  
All services and benefits described in this publication are covered only if  
provided by a contracted LIBERTY Dental Plan participating Primary Care  
Dentist or Specialist. The only time you may receive care outside the  
network is for emergency dental services as described herein under  
“Emergency Dental Care”.  
A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES  
FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL  
RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU  
UPON REQUEST.  
WHO IS ELIGIBLE TO ENROLL  
You are eligible to enroll in LIBERTY Dental Plan. You must live in the  
plan service area. Prospective Group Subscribers must also meet their  
employer’s eligibility requirements.  
WHAT IF I HAVE A QUESTION ABOUT MY DENTAL PLAN  
LIBERTY Dental Plan provides toll-free telephone access to covered  
members. Just call our Member Services Department if you have a question  
or inquiry. Our Member Service representatives will be glad to provide you  
information or resolve your inquiry. Call (888) 703-6999, between the  
hours of 8:00 a.m. to 5:00 p.m. (PST) Monday through Friday.  
HOW DO I RECEIVE CARE  
You must choose a Primary Care Dentist when you enroll in the plan. (See  
note under “Your Dental Plan” regarding selecting a Primary Care Dentist  
EOC – Group (No Dependents)  
Revised 04/11  
4
for plans CA80, CA90, Prestige II and Prestige III.) This dentist will be  
responsible for providing the dental care needs for you, including referring  
you to a specialist should it be necessary (remember you can change dentists  
at anytime by calling LIBERTY Dental Plan or by submitting a request for  
provider change in writing). A directory of participating dentists will be sent  
to you upon request.  
You may select any LIBERTY Dental Plan contracted provider accepting  
your plan. However, you may want to consider a choice convenient to your  
residence or work.  
As a member, you should be able to make an appointment to be seen for  
dental hygiene and routine care within three weeks of the date of your  
request. This is based upon available schedule times.  
HOW TO MAKE AN APPOINTMENT  
After completing your enrollment form, you are eligible to receive care on  
the first of the month following LIBERTY Dental Plan’s receipt of your  
enrollment application and notification of your eligibility by your employer  
or group administrator.  
Be sure to identify yourself as a member of LIBERTY Dental Plan when you  
call the dentist for an appointment. We also suggest that you keep this  
material handy and take this information and the Schedule of Benefits and  
applicable Limitations and Exclusions with you when you go to your  
appointment. You can then reference benefits and applicable co-payments  
which are the out-of-pocket costs associated with your plan.  
HOW DO I FILE A CLAIM FORM  
There are no claim forms to worry about with your plan. LIBERTY Dental  
Plan prepays participating Primary Care Dentists in advance for covered  
services (less applicable co-payments of your plan).  
IS PRIOR BENEFIT AUTHORIZATION NECESSARY  
No prior benefit authorization is required in order to receive dental services  
from your Primary Care Dentist. The Primary Care Dentist has the authority  
to make most coverage determinations. The coverage determinations are  
achieved through comprehensive oral evaluations which are covered by your  
plan. Your Primary Care Dentist is responsible for communicating the  
results of the comprehensive oral evaluation and advising of available  
benefits and associated cost.  
EOC – Group (No Dependents)  
Revised 04/11  
5
If your Primary Care Dentist encounters a situation that requires the services  
of a specialist, LIBERTY Dental Plan requires a preauthorization  
submission, which will be responded to within five (5) business days of  
receipt, unless urgent.  
If you or your Primary Care Dentist encounter an urgent condition in which  
there is an imminent and serious threat to your health, including but not  
limited to the potential loss of life, limb, or other major body function, or the  
normal timeframe for the decision making process as described above would  
be detrimental to your life or health, the response to the request for referral  
should not exceed seventy-two (72) hours from the time of receipt of such  
information. The decision to approve, modify or deny will be communicated  
to the Primary Care Dentist within twenty-four (24) hours of the decision. In  
cases where the review is retrospective, the decision shall be communicated  
to the enrollee within thirty (30) days of the receipt of the information.  
In the event that you need to be seen by a specialist, LIBERTY Dental Plan  
does require prior benefit authorization. Your Primary Care Dentist is  
responsible for obtaining authorization for you to receive specialty care.  
In the instance that there are no contracted specialty providers listed in the  
Provider Directory for your county, benefits will be provided to you as if the  
specialty providers were contracted with the plan.  
If your specialty referral preauthorization is denied or you are dissatisfied  
with the preauthorization, please refer to Page 9, GRIEVANCE  
PROCEDURES.  
INDEPENDENT MEDICAL REVIEW  
In cases which result in the denial of the preauthorization requests by a  
LIBERTY Dental Plan Provider, Subscribers may request a form for the  
independent medical review of their case by contacting LIBERTY Dental  
Plan at (888) 703-6999 or writing to: LIBERTY Dental Plan, P.O. Box  
2
6110, Santa Ana, CA 92799-6110. You may also request the forms from  
the Department of Managed Health Care. The Department of Managed  
Health Care may be reached at (888) HMO-2219 or by visiting their website  
at: http://www.hmohelp.ca.gov.  
EMERGENCY DENTAL CARE  
All affiliated LIBERTY Dental Plan Primary Care Dental offices provide  
availability of emergency dental care services twenty-four (24) hours per  
day, seven (7) days per week.  
EOC – Group (No Dependents)  
Revised 04/11  
6
In the event you require Emergency Dental Care, contact your Primary Care  
Dentist to schedule an immediate appointment. For urgent or unexpected  
dental conditions that occur after-hours or on weekends, contact your  
Primary Care Dentist for instructions on how to proceed.  
If after you contact your Primary Care Dentist and are advised that your  
Primary Care Dentist is not available, simply contact any licensed dentist to  
receive care. Liberty Dental will reimburse you for dental expenses up to a  
maximum of seventy-five dollars ($75), less applicable co-payments.  
The Plan provides coverage for emergency dental services only if the  
services are required to alleviate severe pain or bleeding or if an enrollee  
reasonably believes that the condition, if not diagnosed or treated, may lead  
to disability, dysfunction or death.  
Emergency Dental Service and care include (and are covered by  
LIBERTY Dental Plan), as defined in the California Health & Safety Code,  
a dental screening, examination, evaluation by dentist or dental specialist to  
determine if an emergency dental condition exists, and to provide care that  
would be acknowledged as within professionally recognized standards of  
care and in order to alleviate any emergency symptoms in a dental office.  
Medical and/or psychiatric emergencies are not covered by LIBERTY  
Dental Plan if the services are rendered in a hospital setting which are  
covered by a Medical Plan, or if LIBERTY Dental Plan determines the  
services were not dental in nature.  
Emergency services and care (and are not covered by LIBERTY Dental  
Plan) also means an additional screening and examination, and evaluation  
by a physician, or other personnel to the extent permitted by applicable law  
and within the scope of licensure and clinical privileges, to determine if a  
psychiatric emergency medical condition exists, and the care and treatment  
necessary to relieve or eliminate the psychiatric emergency medical  
condition, within the capability of the facility. LIBERTY Dental Plan does  
not provide coverage for such emergency services and care.  
Reimbursement for Emergency Dental Care: If the requirements in the  
section titled “Emergency Dental Care” are satisfied, LIBERTY Dental Plan  
will cover up to $75 of such services per calendar year. If you pay a bill for  
covered Emergency Dental Care, submit a copy of the paid bill to LIBERTY  
Dental Plan, Claims Department, P.O. Box 26110, Santa Ana, CA 92799-  
6
110. Please include a copy of the claim from the provider’s office or a  
legible statement of services/invoice. Please forward to LIBERTY Dental  
Plan with the following information:  
Your membership information.  
Individual’s name that received the emergency services.  
EOC – Group (No Dependents)  
Revised 04/11  
7
Name and address of the dentist providing the emergency  
service.  
A statement explaining the circumstances surrounding the  
emergency visit.  
If additional information is needed, you will be notified in writing. If any  
part of your claim is denied you will receive a written explanation of benefits  
(EOB) within 30 days of LIBERTY Dental Plan’s receipt of the claim that  
includes:  
The reason for the denial.  
Reference to the pertinent Evidence of Coverage  
provisions on which the denial is based.  
Notice of your right to request reconsideration of the  
denial, and an explanation of the grievance procedures.  
Please refer to Page 9, GRIEVANCE PROCEDURES.  
CONTINUITY OF CARE  
Current Members:  
Current Members may have the right to the benefit of completion of care  
with their terminated provider for certain specified dental conditions. Please  
call the Plan at (888) 703-6999 to see if you may be eligible for this benefit.  
You may request a copy of the Plan'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:  
A New Member may have the right to the qualified benefit of completion of  
care with their non-participating provider for certain specified dental  
conditions. Please call the Plan at (888) 703-6999 to see if you may be  
eligible for this benefit. You may request a copy of the Plan's Continuity of  
Care Policy. You must make a specific request to continue under the care of  
your current 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 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.  
LIBERTY DENTAL PLAN MEMBER SERVICES DEPARTMENT  
LIBERTY Dental Plan Member Services provides toll-free customer service  
support Monday through Friday 8:00 a.m. to 5:00 p.m. on normal business  
EOC – Group (No Dependents)  
Revised 04/11  
8
days to assist members with simple inquiries and resolution of  
dissatisfactions. The hearing and speech impaired may use the California  
Relay Service’s toll-free telephone numbers (800) 735-2929 (TTY) or (888)  
8
7
77-5378 (TTY) to contact the department. Our toll-free number is (888)  
03-6999.  
GRIEVANCE PROCEDURES  
If you are dissatisfied with your selected Primary Care Dentist, personnel,  
facilities, specialty referral, preauthorization, claim, or the dental care you  
receive, grievances may be:  
Sent in writing to LIBERTY Dental Plan,  
P.O. Box 26110, Santa Ana, CA 92799-6110,  
Or  
LIBERTY Dental Plan’s Member Services Department facsimile at  
(949) 223-0011,  
Or  
Contact a LIBERTY Dental Plan Member Services Representative at  
888) 703-6999,  
(
Or  
Use our online grievance filing process by visiting  
www.libertydentalplan.com.  
Grievance Forms may be requested by contacting LIBERTY Dental Plan’s  
Member Services Department at (888) 703-6999. Grievance Forms are also  
available on our website, www.libertydentalplan.com.  
LIBERTY Dental Plan’s representatives will review the problem with you  
and take appropriate steps for a quick resolution. You will receive  
acknowledgement of your grievance within five (5) calendar days of receipt.  
Grievances will be resolved within 30 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 1-888-703-6999 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  
EOC – Group (No Dependents)  
Revised 04/11  
9
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.  
If you are not satisfied with the resolution initially provided, you may  
request a review by LIBERTY Dental Plan’s Quality Management  
Committee or Public Policy Committee. Your requests must be in writing  
with a detailed summary and should be directed to:  
LIBERTY Dental Plan, Inc.  
Quality Management Committee  
P.O. Box 26110  
Santa Ana, CA 92799-6110  
All levels of appeal will be completed within 30 days of receipt.  
ARBITRATION  
If you or one of your eligible dependents is not satisfied with the results of  
LIBERTY Dental Plan’s complaint resolution process, and all the complaint  
resolution procedures have been exhausted, the matter can be submitted to  
arbitration for resolution. If you, or one of your eligible dependents, believe  
that some conduct arising from or relating to your participation as a  
LIBERTY Dental Plan member, including contract or medical liability, the  
matter shall be settled by arbitration. The arbitration will be conducted  
according to the American Arbitration Association rules and regulations in  
force at the time of the occurrence of the grievance (dispute or controversy).  
PREPAYMENT FEES (PREMIUMS); CHANGES TO BENEFITS  
AND PREMIUMS  
LIBERTY Dental Plan provides coverage for you under an agreement with  
your employer or plan administrator, and your employer or plan  
administrator will pay all premiums to us. Your employer or plan  
EOC – Group (No Dependents)  
Revised 04/11  
1
0
administrator will let you know the part you must pay. LIBERTY Dental  
Plan may change the covered benefits, co-payments, and premium rates from  
time to time. LIBERTY Dental Plan will not decrease the covered benefits or  
increase the premium rates during the term of that agreement without giving  
notice to your employer or plan administrator at least sixty (60) days before  
the proposed change.  
TERMINATION OF COVERAGE  
All rights to coverage stop on the date your employer or group coverage is  
terminated. Your employer, plan administrator or LIBERTY Dental Plan has  
the right to cancel the contract and terminate coverage if either party violates  
the terms and conditions of the contract, or upon the contract expiration date.  
If prepayment fees are not paid according to the agreement, termination will  
be effective on midnight of the last day of the month for which prepayment  
fees were last received, subject to compliance with notice requirements and  
accepted by LIBERTY Dental Plan.  
If you terminate from the Plan while the contract between LIBERTY Dental  
Plan and your employer or plan administrator is in effect, your Primary Care  
or Specialty Dentist must complete any procedure in progress that was  
started before your termination, abiding by the terms and conditions of the  
Plan.  
If you terminate coverage from the Plan after the start of orthodontic  
treatment, you will be responsible for any charges on any remaining  
orthodontic treatment.  
If a subscriber permits any other person to use their Member ID Card to  
obtain services under this dental plan or otherwise engages in fraud or  
deception in the use of the services or facilities of the plan or knowingly  
permits such fraud or deception by another, termination will be effective  
immediately upon notice from LIBERTY Dental Plan.  
If an enrollee or subscriber’s coverage is allegedly terminated based on their  
health status or requirements for health care services, a review may be  
requested by the Director of the Department of Managed Health Care. If the  
Director determines that a proper complaint exists under the provisions of  
this section, the Director shall notify the plan. Within 15 days after receipt of  
such notice, the plan shall either request a hearing or reinstate the enrollee or  
subscriber. A reinstatement shall be retroactive to time of cancellation or  
failure to renew and the plan 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. You  
can contact the Department of Managed Health Care at (888) HMO-2219 or  
EOC – Group (No Dependents)  
Revised 04/11  
1
1
on a TDD line at (877) 688-9891 for the hearing and speech impaired. The  
Department’s Internet web site is http://www.hmohelp.ca.gov.  
CONTINUATION OF COVERAGE  
Please check with your employer or plan administrator for eligibility and  
details.  
Congress passed the Consolidated Omnibus Budget Reconciliation Act  
(COBRA) health benefits provisions in 1986. The law amends the  
Employee Retirement Income Security Act (ERISA), the Internal Revenue  
Code and the Public Health Service Act to provide continuation of group  
health coverage that otherwise would be terminated.  
The law generally covers group health plans maintained by employers with  
2
0 or more employees in the prior year. It applies to plans in the private  
sector and those sponsored by state and local governments. The law does  
not, however, apply to plans sponsored by the Federal government and  
certain church-related organizations.  
Qualifying events for employees are:  
●
Voluntary or involuntary termination of employment for reasons other  
than “gross misconduct”  
●
Reduction in the number of hours of employment  
Qualifying events for spouses are:  
●
Termination of the covered employee’s employment for any reason other  
than “gross misconduct”  
●
●
●
●
Reduction in the hours worked by the covered employee  
Covered employee’s becoming entitled to Medicare  
Divorce or legal separation of the covered employee  
Death of the covered employee  
Qualifying events for dependent children are the same as for the spouse  
with one addition:  
●
Loss of “dependent child” status under the plan rules  
EOC – Group (No Dependents)  
Revised 04/11  
1
2
Periods of coverage:  
Qualifying Event  
Beneficiary  
Employee  
Spouse  
Coverage  
●
●
Termination  
Reduced hours  
18 months  
Dependent Child  
●
●
●
●
Employee entitled to Medicare  
Divorce or legal separation  
Death of covered employee  
Loss of “dependent child” status  
Spouse  
Dependent Child  
36 months  
36 months  
Special rules for disabled individuals may extend the maximum periods of  
coverage. If a qualified beneficiary is determined under Title II or XVI of  
the Social Security Act to have been disabled at the time of a termination of  
employment or reduction in hours of employment and the qualified  
beneficiary properly notifies the plan administrator of the disability  
determination, the 18-month period is expanded to 29 months.  
Qualified beneficiaries have the right to elect to continue coverage that is  
identical to the coverage provided under the plan. Employers and plan  
administrators have an obligation to determine the specific rights of  
beneficiaries with respect to election, notification and type of coverage  
options. Qualified beneficiaries must be offered benefits identical to those  
received immediately before qualifying for continuation coverage.  
Beneficiaries may be required to pay the entire premium for coverage. It  
cannot exceed 102 percent of the cost to the plan for similarly situated  
individuals who have not incurred a qualifying event. Premiums reflect the  
total cost of group health coverage, including both the portion paid by  
employees and any portion paid by the employer before the qualifying event,  
plus two percent for administrative costs.  
For disabled beneficiaries receiving and additional 11 months of coverage  
after the initial 18 months, the premium for those additional months may be  
increased to 150 percent of the plan’s total cost of coverage.  
Recent legislation in California provides for continuation of coverage for  
Federal COBRA beneficiaries enrolled in California health plans. This Cal-  
COBRA coverage is governed by California law. The idea behind Cal-  
COBRA’s extension of Federal COBRA coverage is to provide California  
enrollees who exhaust their COBRA coverage additional coverage under  
California law, as well as to provide uniformity in its duration.  
Other Cal-COBRA is coverage available under California law and applies to  
employers who have 2 to 19 employees (small group employers). Recent  
EOC – Group (No Dependents)  
Revised 04/11  
1
3
California legislation expands the duration of coverage for these enrollees in  
Cal-COBRA. The idea of Cal-COBRA is to provide the same general  
advantages to small groups in California as federal COBRA provides to  
larger groups.  
You may enroll in Cal-COBRA if you are either one of the following and  
meet certain criteria:  
1
.
An employee of an employer with more than 20 employees (or a  
dependent of such an employee) and you are continuing coverage after  
exhausting federal COBRA coverage.  
If you are covered under federal COBRA, you exhaust federal COBRA and  
you had less than 36 months of COBRA coverage, you may have the  
opportunity to continue coverage for up to a total of 36 months through a  
combination of COBRA and Cal-COBRA.  
This Cal-COBRA extension of Federal COBRA takes effect September 1,  
2
003, and applies to individuals who begin receiving COBRA coverage on  
or after January 1, 2003.  
When you extend your Federal COBRA coverage under Cal-COBRA, you  
have the opportunity to receive the same benefits in the same health plan as  
under COBRA. However, if you have non-medical coverage under COBRA  
(dental or vision care) from a specialized health plan, you can not continue  
this under Cal-COBRA.  
2
. An employee of a small employer (2 – 19 employees) (or a dependent of  
such an employee) and have a “qualifying event”.  
Qualifying events for Cal-COBRA if you are an employee of an  
employer with 2 – 19 employees (or the spouse or dependent of such an  
employee):  
●
Loss of coverage because employment of the covered employee ends  
(unless employment ends because of gross misconduct of the employee), or  
loss of coverage because the hours of the covered employee’s employment  
are reduced  
●
Loss of coverage because of divorce or legal separation from the covered  
employee  
●
Loss of coverage because one is no longer a dependent of the employee  
under the group plan  
●
Loss of coverage because the covered employee has become eligible for  
Medicare  
●
Loss of coverage because of the death of the covered employee  
EOC – Group (No Dependents)  
Revised 04/11  
1
4
You are not eligible for Cal-COBRA if you are one of the following:  
●
Eligible for Medicare  
●
Covered by another group health plan, when your group plan is with an  
employer of 2 – 19 employees, unless:  
a. that other group health plan has a pre-existing condition  
exclusion or limitation that applies to you;  
b. that other group health plan is a group conversion plan  
(basically the offer of an individual plan) that you choose not to  
accept.  
●
●
Terminated from employment because of gross misconduct  
Someone who fails to timely choose Cal-COBRA in writing when it is  
available  
●
●
Someone who fails to timely pay the required premium for Cal-COBRA  
Someone whose allowed eligibility period has been used up  
Anyone covered under Cal-COBRA has the same benefits as active covered  
employees. If the group plan offers special coverage, such as dental or  
vision coverage, that must be provided to the Cal-COBRA enrollee as well,  
unless you are continuing from federal COBRA as indicated above.  
Duration of coverage if Cal-COBRA coverage began before  
January 1, 2003:  
●
If a former employee gets Cal-COBRA coverage because employment  
ended or because working hours were reduced, Cal-COBRA for the  
former employee, spouse, and dependents may continue for up to 18  
months.  
●
If the former employee’s spouse or dependent gets Cal-COBRA  
coverage because of any of the following reasons, their coverage may  
continue for up to 36 months:  
a. death of the former employee  
b. divorce or legal separation from the former employee  
c. the former employee becomes eligible for Medicare  
d. the dependent is no longer considered a dependent under the  
group plan  
●
Certain people found eligible for Social Security Disability may be  
eligible for up to 29 months.  
Duration of coverage if Cal-COBRA coverage beginning on or after  
January 1, 2003:  
●
If a former employee gets Cal-COBRA coverage because employment  
ended or because working hours were reduced, Cal-COBRA for the  
former employee, spouse, and dependents may continue for up to 36  
months.  
EOC – Group (No Dependents)  
Revised 04/11  
1
5
●
●
If the former employee’s spouse or dependent gets Cal-COBRA  
coverage because of any of the following reasons, their coverage may  
continue for up to 36 months:  
a. death of the former employee  
b. divorce or legal separation from the former employee  
c. the former employee becomes eligible for Medicare  
d. the dependent is no longer considered a dependent under the  
group plan  
Certain people found eligible for Social Security Disability may be  
eligible for up to 36 months.  
Cal-COBRA ends when:  
●
●
●
●
●
●
The time period stated in the law passes (no more than 36 months)  
Premiums are not paid when due  
The covered person moves outside the health plan’s service area  
The employer no longer offers any health coverage to its employees  
The covered person becomes entitled to Medicare  
The covered person enrolls in another group policy  
MEMBER RIGHTS  
As a member, you have the right to:  
*
Be treated with respect, dignity and recognition of your need for privacy  
and confidentiality  
*
*
*
*
*
*
Express grievances and be informed of the grievance process  
Have access and availability to care  
Access your dental records  
Participate in decision-making regarding your course of treatment  
Be provided information regarding a provider  
Be provided information regarding the organization’s services, benefits  
and specialty referral process.  
LIBERTY Dental Plan Policies and Procedures for preserving the  
confidentiality of medical records are available and will be furnished to you  
upon request.  
MEMBER RESPONSIBILITIES  
As a member, you have the responsibility to:  
*
*
Identify yourself to your selected dental office as a LIBERTY Dental  
Plan member  
Treat the Primary Care Dentist, office staff and LIBERTY Dental Plan  
staff with respect and courtesy  
EOC – Group (No Dependents)  
Revised 04/11  
1
6
*
*
Keep scheduled appointments or contact the dental office twenty-four  
24) hours in advance to cancel an appointment  
Cooperate with the Primary Care Dentist in following a prescribed  
course of treatment  
(
*
*
*
Make co-payments at the time of service  
Notify LIBERTY Dental Plan of changes in family status  
Be aware of and follow the organization’s guidelines in seeking dental  
care  
LIBERTY Dental Plan of California, Inc.  
Limitations  
1
2
3
.
.
.
Prophylaxes are covered once every six consecutive months.  
Full Mouth X-rays are limited to once every 36 consecutive months.  
Fluoride Treatments are covered once every 6 consecutive months, up to  
th  
the 18 birthday.  
4
5
.
.
Sealants are covered only on the first and second permanent molars and  
up to the 14 birthday.  
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.  
th  
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
8
.
.
Denture Relines are covered twice per year, and only when consistent  
with professionally recognized standards of dental practice.  
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.  
LIBERTY Dental Plan of California, Inc.  
Exclusions  
1
2
.
.
Any procedure not specifically listed as a Covered Benefit.  
Replacement of lost or stolen prosthetics or appliances including  
crowns, bridges, partial dentures, full dentures, and orthodontic  
appliances.  
3
4
.
.
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.  
Procedures considered experimental, treatment involving implants or  
pharmacological regimens (see “Independent Medical Review” on Page  
7
).  
5
6
.
.
Oral surgery requiring the setting of bone fractures or bone dislocations.  
Hospitalization.  
EOC – Group (No Dependents)  
Revised 04/11  
1
7
7
8
9
1
1
1
1
.
.
.
Out-patient services.  
Ambulance services.  
Durable Medical Equipment.  
0. Mental Health services.  
1. Chemical Dependency services.  
2. Home Health services.  
3. General anesthesia, analgesia, intravenous/intramuscular sedation or the  
services of an anesthesiologist.  
1
1
4. Treatment started before the member was eligible, or after the member  
was no longer eligible.  
5. 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.  
6. Procedures which are determined not to be dentally necessary consistent  
with professionally recognized standards of dental practice.  
7. Treatment of malignancies, cysts, or neoplasms.  
1
1
1
8. Orthodontic treatment started prior to member’s effective date of  
coverage.  
1
2
9. Appliances needed to increase vertical dimension or restore occlusion.  
0. 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.  
LIBERTY Dental Plan of California, Inc.  
Orthodontic Exclusions  
1
2
.
.
Lost, stolen or broken appliances.  
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).  
Temporomandibular joint syndrome (TMJ) surgical orthodontics.  
Myofunctional therapy.  
Treatment of cleft palate.  
Treatment of micrognathia.  
Treatment of macroglossia.  
3
4
5
6
7
.
.
.
.
.
DEFINITIONS  
Co-payment: Any amount charged to a member at the time of service for  
covered services. Fixed co-payment amounts are listed in the Schedule of  
Benefits.  
EOC – Group (No Dependents)  
Revised 04/11  
1
8
Dental Records: Refers to diagnostic aid, intraoral and extra-oral  
radiographs, written treatment record including but not limited to progress  
notes, dental and periodontal chartings, treatment plans, consultation reports,  
or other written material relating to an individual’s medical and dental  
history, diagnosis, condition, treatment, or evaluation.  
Emergency Dental Service: Emergency Dental Service and care include  
(and are covered by LIBERTY Dental Plan) dental screening, examination,  
evaluation by dentist or dental specialist to determine if an emergency dental  
condition exists, and to provide care that would be acknowledged as within  
professionally recognized standards of care and in order to alleviate any  
emergency symptoms in a dental office. Medical emergencies are not  
covered by LIBERTY Dental Plan if the services are rendered in a hospital  
setting which are covered by a Medical Plan, or if LIBERTY Dental Plan  
determines the services were not dental in nature.  
Group (or Organization): Employer group or other entity which has  
contracted with LIBERTY Dental Plan to arrange for the provision of the  
benefits of this Plan.  
Member: Subscriber who is actually enrolled in the Plan.  
Non-Participating Provider: A dentist that has no contract to provide  
services for the Plan  
Primary Care Dentist: A dentist affiliated with the Plan to provide services  
to covered members of the Plan. The Primary Care Dentist is responsible to  
provide or arrange for needed dental services.  
Provider: A dentist providing services under contract with the Plan.  
Plan: LIBERTY Dental Plan of California, Inc.  
Specialist: Refers to Endodontists, Oral Surgeons, Orthodontists, Pediatric  
Dentists or Periodontists.  
Terminated Provider: A dentist that formerly delivered services under  
contract that is no longer associated with the Plan.  
ANSWERS TO COMMON QUESTIONS  
Are my cleanings covered?  
Yes. LIBERTY Dental Plan covers routine cleanings (prophylaxis) at your  
selected dental office once every 6 months. Some members may require  
more than a “routine” cleaning due to more involved dental needs. When  
EOC – Group (No Dependents)  
Revised 04/11  
1
9
more frequent cleanings or extensive treatment, such as root planing or  
scaling are required, your dentist may charge you in accordance with your  
dental plan.  
What if I have a pre-existing condition?  
Most pre-existing conditions are covered. However, a procedure started  
prior to your coverage effective date will not be covered by the Plan.  
Are there waiting periods to be met?  
No. Once your enrollment become effective, simply make an appointment  
with your selected network dentist.  
Does the Plan include dental specialists?  
Yes. LIBERTY Dental Plan has a contracted network of Dental Specialists.  
If specialty is deemed necessary by your Primary Care Dentist, you will be  
referred to a specialist after coordinating your needs with your Primary Care  
Dentist.  
What if I have other dental coverage?  
Your LIBERTY Dental Plan network Primary Care Dentist will apply your  
reimbursement from any additional coverage you have to your co-payment if  
allowable by your other dental plan carrier. This may reduce your out-of-  
pocket costs.  
How will I know what my co-payment will be?  
Refer to your Schedule of Benefits which lists all of the services covered  
under your plan. The co-payment schedule is listed by ADA code. If you  
have any questions, ask your dentist before you receive services and/or call  
the LIBERTY Dental Plan Member Services Department.  
Who do I call if I have a question?  
If you have a question about enrollment, talk to your Benefits Manager.  
Should you have questions once you become a member, contact our Member  
Services Department.  
LIBERTY Dental Plan of California, Inc.  
P.O. Box 26110  
Santa Ana, CA 92799-6110  
(
888) 703-6999  
EOC – Group (No Dependents)  
Revised 04/11  
2
0
NEW MEMBER CONTINUATION OF  
CARE INFORMATION  
AND PRIVACY STATEMENT  
Dear New LIBERTY Dental Plan Member:  
If you have been receiving care from a dental care provider, you may have a  
right to keep your dental care provider for a designated time period. Please  
contact LIBERTY Dental Plan’s Member Services Department at (888) 703-  
6
999, and if you have further questions, you are encouraged to contact the  
Department of Managed Health Care, which protects HMO consumers. You  
can contact the Department of Managed Health Care by telephone at its toll-  
free number (888) HMO-2219, or at a TDD number for the hearing impaired  
at (877) 688-9891, or online at www.hmohelp.ca.gov. You may also obtain  
a copy of LIBERTY Dental Plan’s policy on continuation of care from our  
Member Services Department. This policy does not apply to a newly  
covered enrollee covered under an individual subscriber agreement.  
You must make a specific request to continue under the care of your current  
provider. LIBERTY Dental Plan is not required to continue your care with  
that provider if you are not eligible under our policy or if we cannot reach an  
agreement with your provider on the terms regarding your care in accordance  
with California law.  
Privacy Statement  
We protect the privacy of our members’ health information as required by  
law, accreditation standards and our internal policies and procedures. This  
Notice explains our legal duties and your rights as well as our privacy  
practices.  
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT  
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET  
ACCESS TO THIS INFORMATION.  
CAREFULLY.  
PLEASE REVIEW IT  
We collect, use and disclose information provided by and about you for  
health care/dental payment and operations, or when we are otherwise  
permitted or required by law to do so.  
EOC – Group (No Dependents)  
Revised 04/11  
2
1
For Payment: We may use and disclose information about you in managing  
your account or benefits, and paying claims for medical/dental care you  
receive through your plan. For example, we maintain information about  
your premium and deductible payments. We may also provide information  
to a doctor/dentist’s office to confirm your eligibility for benefits or we may  
ask a doctor/dentist for details about your treatment so that we may review  
and pay the claims for your dental care.  
For Health/Dental Care Operations: We may use and disclose medical/dental  
information about you for our operations. For example, we may use  
information about you to review the quality of care and services you receive,  
or to evaluate a treatment plan that is being proposed for you.  
We may contact you to provide information about treatment alternatives or  
other health-related benefits and services. For example, when you or your  
dependents reach a certain age, we may notify you about additional  
programs or products for which you may become eligible, such as individual  
coverage.  
We may, in the case of some group health plans, share limited health  
information with your employer or other organizations that help pay for your  
membership in the plan, in order to enroll you, or to permit the plan sponsor  
to perform plan administrative functions. Plan sponsors receiving this  
information are required, by law, to have safeguards in place to protect it  
from inappropriate uses.  
As Permitted or Required by Law: Information about you may be used or  
disclosed to regulatory agencies, such as during audits, licensure or other  
proceedings; for administrative or judicial proceedings; to public health  
authorities; or to law enforcement officials, such as to comply with a court  
order or subpoena.  
Authorization: Other uses and disclosures of protected health information  
will be made only with your written permission, unless otherwise permitted  
or required by law. You may revoke this authorization, at any time, in  
writing. We will then stop using your information. However, if we have  
already used your information based on your authorization, you cannot take  
back your agreement for those past situations.  
Your Rights  
Under new regulations that will be effective in April 2003, you will have  
additional rights over your health/dental information. Under the new rules,  
you will have the right to:  
EOC – Group (No Dependents)  
Revised 04/11  
2
2
o
o
Request restrictions on certain uses and disclosures of your  
protected health/dental information. However, we are not required  
to agree to a requested restriction.  
Receive confidential communications of protected health/dental  
information, using reasonable alternative means or at an alternative  
address, if communications to your home address could endanger  
you.  
o
o
o
Inspect and copy protected health/dental information. To obtain a  
copy of such information, please send us a written request. You  
also have the right to amend the information if you believe it is  
incomplete or inaccurate. If we did not create the information, we  
will refer you to the source, such as your doctor/dentist.  
Receive an accounting of our disclosures of your medical  
information, except when those disclosures are made for treatment,  
payment or health care/dental operations, or the law otherwise  
restricts the accounting. We are not required to give you a list of  
disclosures made before April 14, 2003.  
If you have agreed to receive this notice electronically, you are still  
entitled to a paper copy upon request.  
Complaints  
If you believe your privacy rights have been violated, you have the right to  
file a complaint with us, and/or with the Federal Government. You will not  
be penalized for filing a complaint.  
Copies and Changes  
You have the right to receive an additional copy of this notice at any time.  
We reserve the right to change the terms of this notice. A revised notice will  
be effective for information we already have about you as well as any  
information we may receive in the future. We are required by law to comply  
with whatever privacy notice is currently in effect. We will communicate  
any changes to our notice through subscriber newsletters, direct mail or our  
website, www.libertydentalplan.com.  
Contact Information  
If you want to exercise your rights under this notice, or if you wish to  
communicate with us about privacy issues, or to file a complaint with us,  
please contact our Member Services Department at (888) 703-6999.  
EOC – Group (No Dependents)  
Revised 04/11  
2
3