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.