DESCRIPTION OF SERVICES AND DISCLOSURE FORM

DESCRIPTION OF SERVICES AND DISCLOSURE FORM
The following is a Description of the discount dental plan available to you and your
family members through Coastal Dental, Inc. The Description completely describes the plan
and your rights under the plan, and if you choose to enroll it is your contract with Coastal
Dental. You should read this carefully. PLEASE READ THE FOLLOWING
INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF
PROVIDERS DENTAL CARE MAY BE OBTAINED. If you have any questions about this
Description please call Coastal Dental, Inc. at 1-800-874-1986.
1.
Contact Information. The full name of the plan is Coastal Dental, Inc. Coastal
Dental, Inc. is located at 601 Daily Drive, Suite 205, Camarillo, CA 93010. The phone
number is 1-800-874-1986.
2.
Type of Plan. This is a discount fee plan. THIS IS NOT INSURANCE. By
paying an annual enrollment fee to Coastal Dental (see Section 10 below) you (and if
applicable your eligible family members) will be entitled to receive dental services at reduced
rates. A complete description of the reduced rates for dental services is set forth in Section
11 below.
3.
Definitions. As used in this Description, “Eligibility” means you or your
family’s right to receive dental services at reduced rates. “Eligible family members” means
your spouse and your dependent children who are under age 18 (or under age 23 if attending
school on a full-time basis), or who are incapable of self-sustaining employment by reason of
a physical or mental disability, injury, illness, or condition, and who are dependent on you for
support and maintenance. “Network Dentist” means a dentist who has agreed with Coastal
Dental to provide services at the reduced rates set forth in this Description. “Specialist
services” are periodontics, endodontics, orthodontics, and oral surgery. “Specialist” is a
dentist who performs only a specialist service.
4.
Choice of Dentists. To be entitled to the reduced rates you and your eligible
family members must visit a Network Dentist. If you receive services from a dentist who is
not a Network Dentist you will not be entitled to the discount fees provided by the plan. You
can visit any Network Dentist, including the Network Dentist whose name and address are
included with this brochure. If you want the name and location of other nearby Network
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DESCRIPTION OF SERVICES AND DISCLOSURE FORM
Dentists, or if you have a question about Coastal’s Network Dentists, just call Coastal Dental
at 1-800-874-1986.
5.
Scope of Eligibility. You can select eligibility for you alone, for you and your
spouse, or for you and all of your eligible family members.
6.
Commencement of Services. Once you have read through this Description,
you should complete the Enrollment Form included in this brochure. The completed
Enrollment Form should be sent to Coastal Dental (at the address set forth on the Form)
along with your payment for the one-time processing fee and the initial annual enrollment
fee. Payment may be made by check or credit card. Once your Enrollment Form and fees
are received and processed, Coastal will send you an identification card. If you elect
services for your eligible family members they will receive identification cards as well.
Eligibility begins when you receive your identification card. You must present your
identification card to your Network Dentist before you receive treatment.
7.
Term and Termination of Services. Your and your eligible family members’
right to receive services will continue for one year from the time Coastal Dental receives
your initial annual enrollment fee. The termination date will appear on your identification
card, and will end on midnight on that date. However, eligibility for your spouse will
terminate upon your divorce from him or her, and eligibility for any child will terminate once
the child exceeds the age limit described in Section 3 above.
Notwithstanding the above, if upon reaching the age limit in Section 3 your
child is incapable of self-sustaining employment because of a mental or physical disability,
injury, illness, or condition, and is chiefly dependent on you for support and maintenance,
then eligibility for that child will continue through the term of your enrollment and any
reenrollment. However, you must furnish proof to Coastal of such incapacity and
dependency within sixty (60) days after you receive notice that your child’s eligibility will
terminate. Such notice will be given at least ninety (90) days before your child reaches the
limiting age. Coastal will make a determination of your child’s incapacity and dependency
status, and will so notify you, before your child’s eligibility ends. If Coastal fails to notify
you of its determination by such time, your child’s eligibility will continue until you receive
such notice.
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DESCRIPTION OF SERVICES AND DISCLOSURE FORM
Your right to receive services at the discounted fees described in this plan will
end at the expiration of your one-year term unless you reenroll as described in Section 8
below. Upon termination your Network Dentist will complete all procedures started prior to
termination at the rates set forth in Section 11.
8.
Renewal of Eligiblity. You can renew your right to receive discounted fee
services for an additional year by paying an annual reenrollment fee to Coastal Dental before
your initial eligibility terminates. Coastal Dental will send you a written notice about this at
least thirty (30) days prior to the expiration of eligibility. The reenrollment fee may be
different from the initial annual enrollment fees described in Section 10 below. You will be
told what the applicable fee is in your renewal notice. Upon reenrollment you (and if
applicable your eligible family members) will receive new identification cards.
The same procedure will be used to reenroll for succeeding years. Other than
payment of the required reenrollment fee, there are no conditions or restrictions on your right
to reenroll.
9.
Cancellation of Services. You will have forty-five (45) days after you receive
your identification card(s) to cancel your eligibility and receive a full refund of your
enrollment fee (but not the processing fee). However, no cancellation will be permitted if
you or any eligible family member received services from a Network Dentist during this 45day period. To receive your refund you must return to Coastal (at the address in Section 1
above) all identification cards that were given to you and your family members, along with a
written request for the refund.
Other than as stated above, you cannot cancel any enrollment or reenrollment
and receive any refund of your enrollment or reenrollment fee. However, you can terminate
your eligibility after any one-year period by simply choosing not to reenroll.
Coastal Dental cannot cancel your enrollment, or refuse to permit you to
reenroll after any one-year period of eligibility ends, unless you or any of your eligible
family members has engaged in fraud in using this plan. However, if you believe that
Coastal has cancelled your enrollment or refused reenrollment because of your or any family
member’s health status, you may contact the California Department of Managed Health Care
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DESCRIPTION OF SERVICES AND DISCLOSURE FORM
at 1-888-HMO-2219 (for hearing or speech impaired persons at 1-877-688-9891) or contact
the Department on-line at www.hmohelp.ca.gov.
10.
Processing and Enrollment Fees. Upon enrollment you will pay a one-time
processing fee of $15.00 and your initial enrollment fee. Applicable enrollment fees for the
initial year of services are as follows:
You Only:
You and Your Spouse:
You and All of Your Eligible Family Members:
$96.00
$120.00
$144.00
As noted in Section 8, reenrollment fees for years after your initial year of
services may be different.
You will pay the one-time processing fee and the initial enrollment fee through
your preferred credit card or other payment method as described in the Enrollment Form that
follows this Description.
11.
Dental Services and Fees. Following this Description is a complete list of
covered dental services and the fees your Network Dentist will charge for these services.
Please note that this is the fee schedule currently in effect for your area.
Coastal reserves the right to change the fee schedule at any time and any new fee schedule
will apply to all dental services received by you or your family members thirty (30) days
after Coastal Dental mails you written notice of the new schedule.
12.
Other Charges. There are no copayments, deductibles, or other charges of any
kind under this plan. All that you have to do is pay your Network Dentist for the discounted
services that you or your eligible family members receive.
13.
Limitations and Exclusions. The following is a complete list of all limitations
and exclusions under this Plan:
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DESCRIPTION OF SERVICES AND DISCLOSURE FORM
Discounts for treatments of fractures or dislocations, congenital malformations,
malignancies, cysts or neoplasms, or Temporomandibular Joint Syndrome (TMJ) are
not provided.
Discounts for prescription drugs and over the counter drugs are not provided.
Prophylaxis (Cleaning) is limited to once every six months.
Full mouth x-rays are limited to once every 24 months.
Replacement of partial dentures is limited to once every five years.
Full upper and/or lower dentures are not to exceed one each in any five-year
period.
Denture relines are limited to one per arch in any 12 month period.
Services performed by a non-participating provider are not covered.
Work in progress that has commenced prior to enrollment must be completed by
the dentist who started the work (whether or not a Network Dentist) and will not be
covered by the discount fees in this plan.
14.
Your Responsibility for Payment of Fees. Once you or any of your eligible
family members receive services from a Network Dentist, your Network Dentist will bill you
directly for those services at the rates set forth in the Fee Schedule. You will pay the billed
amount to your Network Dentist.
If Coastal should ever become liable to your Network Dentist for any reason,
your Network Dentist will not hold you responsible for such liability.
This is a discount dental fee plan only. No amounts are payable by Coastal
Dental either to you or to your Network Dentist.
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DESCRIPTION OF SERVICES AND DISCLOSURE FORM
15.
Disputes. Coastal Dental maintains a grievance system to handle any dispute
or grievance you may have with your Network Dentist or with Coastal itself. You can obtain
a grievance form from your Network Dentist or you can complete a grievance form on-line at
www.coastaldental.com.
You can submit a grievance in writing or by telephone. Coastal’s address is 601
Daily Drive, Suite 205, Camarillo, CA 93010, and its telephone number is 1-800-874-1986.
You have one hundred and eighty (180) days to file a grievance after any
incident or action. Coastal will acknowledge receipt of your grievance within five (5)
calendar days after Coastal receives it. Coastal will notify you of the resolution of your
grievance within thirty (30) days after receipt.
If you are not satisfied with Coastal’s resolution you can seek review from the
Department of Managed Health Care at 1-888-HMO-2219 (for hearing or speech impaired
persons at 1-877-688-9891) or contact the Department on-line at www.hmohelp.ca.gov.
For a more complete description of Coastal’s grievance system please visit
Coastal’s website at www.coastaldental.com.
California law requires Coastal to provide you with the following notice:
“The California Department of Managed Health Care is responsible for regulating
discounted fee plans. If you have a grievance against your plan, you should first
telephone your plan at 1-800-874-1986 and use your plan’s grievance 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 that has not been satisfactorily resolved by the Plan, or with a grievance
that has remained unresolved for more than 30 days, you may call the department
for assistance. The department has a toll-free telephone number (1-888-466-2219)
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
and instructions online.”
16.
Specialist Services. Not all Network Dentists provide specialist services, and
some specialist services may need to be performed by a specialist. You will receive the
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DESCRIPTION OF SERVICES AND DISCLOSURE FORM
discounted fees for specialist services under this Plan only if those services are received from
a Network Dentist. If your Network Dentist does not provide specialist services, you can call
Coastal to see if there is a nearby Network Dentist who can perform specialist services. You
do not need a referral from Coastal to see a Network Dentist who provides such services.
17.
Office Hours and Emergency Services. Your Network Dentist will be open
during normal work hours, Monday through Friday. Your Network Dentist will arrange for
emergency dental care, which will be available 24 hours a day, 7 days a week. . If you need
after-hours care, call your Network Dentist and you will be told what to do. You can also
call Coastal at 1-800-874-1986 for assistance with after-hours care.
18.
Termination of Network Dentist. If your Network Dentist terminates, Coastal
will promptly notify you if it knows who your Network Dentist is so that you can make
arrangements to see another Network Dentist. Also, Coastal will post a notice on its website
(at www.coastaldental.com) listing all Network Dentists who have given notice of
termination, who are being terminated, or who otherwise are unable to provide services. The
notice will state the effective date of termination. Also, you can always call Coastal at the
number in Section 1 above to see whether your dentist is still a Network Dentist.
Coastal’s contract with each Network Dentist specifies that upon termination of
the contract the Network Dentist must complete all procedures commenced prior to
termination at the discounted rates set forth in Section 11.
If Coastal should ever cease operations your Network Dentist will continue to
render discount services to you and your eligible family members for the duration of your
enrollment.
19.
If You Have Dental Insurance. Since Coastal does not provide insurance it
does not coordinate benefits with any dental insurance you or your family members may
have. If you have dental insurance, you should contact your dental insurer to see what
benefits will be paid.
20.
Application of State Law. Coastal Dental is subject to the requirements of
Chapter 2.2 of Division 2 of the Code and of Chapter 1 of Title 28 of the California Code or
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Regulations, and any provision required to be in the contract by either of the above shall bind
Coastal whether or not provided in this Description.
21.
Confidentiality. Each Network Dentist and Coastal Dental itself is required
by law to keep your personal healthcare information confidential. No such information can
be released except with your consent or as expressly authorized by law.
A statement describing our policies and procedures for preserving the confidentiality
of medical records is available and will be furnished to you upon request.
22.
Summary of Discounts. The following is a summary of the major categories
of dental services available under this Plan, and the average fee discount for each category of
services. The average discount is the difference between what your Network Dentist charges
and what a typical dentist usually and customarily charges, as determined by the National
Dental Advisory Service.
THIS IS ONLY A SUMMARY. YOU SHOULD CONSULT THE FEE
SCHEDULE TO DETERMINE THE EXACT FEE FOR ANY PARTICULAR
DENTAL SERVICE.
SERVICE CATEGORY
Diagnostic
Preventive
Restorative
Endodontics
Periodontics
Prosthodontics (Removable)
Maxillofacial Prosthetics
Implant Services
Prosthodontics (Fixed)
Oral and Maxillofacial Surgery
Orthodontics
Adjunctive Services
Description of Services and Disclosure Form C2009S
AVERAGE DISCOUNT
72%
40%
42%
32%
29%
50%
52%
39%
43%
61%
45%
47%
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DESCRIPTION OF SERVICES AND DISCLOSURE FORM
California law requires all health care service plans to give members of the public the
following information about the applicability of, and any copayments or limitations on, the
following:
(A)
(B)
(C)
(D)
(E)
(F)
Deductibles
Lifetime Maximums
Professional Services
Outpatient Services
Hospitalization Services
Emergency Health Coverage
-
(G)
(H)
(I)
(J)
(K)
(L)
(M)
Ambulance Services
Prescription Drug Coverage
Durable Medical Equipment
Mental Health Services
Chemical Dependency Services
Home Health Services
Other
-
None
None
Dental Services Only
Not Applicable
Not Applicable
Available 24 hours a day,
7 days a week
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
IF YOU COMPLETE AND SUBMIT THE ENROLLMENT FORM, YOU AGREE TO
BE BOUND BY ALL OF THE TERMS AND CONDITIONS IN THIS DESCRIPTION.
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