access dental plan individual family dental hmo

HBEX-EOC-IP-CA-17

AccessDentalPlanIndividualFamilyDentalHMO

IndividualEssentialHealthBenefitDentalProgramCombinedEvidenceofCoverageandDisclosureForm/Contract

Providedby:

DHMOBenefitsProvidedbyAccessDentalPlan

8890CalCenterDrive

Sacramento,CA95826

Phone:(844)561‐5600

Email:[email protected]

Website: www.premierlife.com

HBEX-EOC-IP-CA-17

WelcometoAccessDentalPlan!Wearepleasedyouselectedusasyourdentalplan.

Enclosedarethefollowing:

1–InformationregardingyourindividualPlanbenefits.

2–Informationonobtainingservicesduringadentalemergency.

3–YourCombinedEvidenceofCoverageandDisclosureForm/Contract.

AccessDentalPlanisproudtoprovideyouwithdentalcoverage.Goodoralhealthisessentialforoverallwell‐being.Webelievethatabalanceddiet,routinebrushingandregularcheck‐upsarenecessaryingredientsinachievinggoodoralhealth.

Pleasereviewtheinformationincludedinthispacketandcontactyourprimarycaredentisttoarrangeyourfirstappointment.Ifyouhaveanyquestions,pleasecallusat(844)561‐5600.

Again,thankyouforselectingAccessDental.Welookforwardtoservingyou.

HBEX-EOC-IP-CA-17

COMBINEDEVIDENCEOFCOVERAGEANDDISCLOSUREFORM/CONTRACT(“CONTRACT”)

This booklet is a CombinedEvidence of Coverage andDisclosureForm/Contract (“Contract”) for yourAccessDentalPlan(AccessDental)IndividualDentalProgram(“Program”)providedby:AccessDentalPlan,Inc.8890CalCenterDriveSacramento,CA95826Thisbookletdiscloses the termsandconditionsof theProgramavailable inCalifornia. PLEASEREADTHEENTIREDOCUMENTCOMPLETELYANDCAREFULLY. Youhavea right to review thisContractprior toenrollment. Personswithspecialhealthcareneedsshouldread, completelyandcarefully, thesectionentitled“SpecialNeeds.”PLEASE READ THE FOLLOWING INFORMATION SO THAT YOUWILL KNOW HOW TO OBTAINDENTAL SERVICES. YOU MUST OBTAIN DENTAL BENEFITS FROM (OR BE REFERRED FORSPECIALTYSERVICESBY)YOURASSIGNEDCONTRACTDENTIST.AmatrixdescribingtheProgram’smajorBenefitsandcoverage’scanbefoundonthefollowingpage.ADDITIONALINFORMATIONABOUTYOURBENEFITSISAVAILABLEBYCALLINGTHECUSTOMERSERVICE DEPARTMENT AT (844) 561‐5600, 6AM TO 6PM, PACIFIC TIME, MONDAY THROUGHFRIDAY.EntireContractYour enrollment form, this Combined Evidence of Coverage and Disclosure Form/Contract and anyattachmentsorinsertsincludingtheScheduleofBenefitsandLimitationsandExclusions,constitutestheentireagreementbetweentheparties.Tobevalid,anychangesinthecontractmustbeapprovedbyanofficer of Access Dental and attached to it. No agent may change the Contract or waive any of theprovisions.If anyprovisionof this contract is held tobe illegal or invalid for any reason, suchdecisions shallnotaffect the validity of the remaining provisions of this contract, but such remaining provisions shallcontinue in full force and effect unless the illegality and invalidity prevent the accomplishment of theobjectivesandpurposesofthiscontract.ASTATEMENTDESCRIBINGACCESSDENTAL’SPOLICIESANDPROCEDURESFORPRESERVINGTHECONFIDENTIALITY OF MEDICAL RECORDS IS INCLUDED IN THIS COMBINED EVIDENCE OFCOVERAGEANDDISCLOSUREFORM/CONTRACTUNDER“PRIVACYPRACTICES”.

HBEX-EOC-IP-CA-17

DentalPlanCoveredBenefitsMatrixInformationConcerningBenefitsUndertheAccessDentalProgram

THISMATRIXISINTENDEDTOBEUSEDTOHELPYOUCOMPARECOVERAGEBENEFITSANDISASUMMARYONLY.THISBENEFITDESCRIPTIONSECTIONSHOULDBECONSULTEDFORADETAILEDDESCRIPTIONOFPROGRAMBENEFITSANDLIMITATIONS. SEEALSO,EXCLUDEDBENEFITSANDTHESCHEDULEOFBENEFITS.

ProcedureCategory Child‐ONLY*CopayRange

Adult‐Only**CopayRange

DiagnosticandPreventiveOralExam,PreventiveCleaning,TopicalFluorideApplication,SealantsperTooth,Preventive‐X‐raysandSpacemaintainers‐Fixed

$0 $0

BasicServicesRestorativeProcedures,PeriodontalMaintenanceServices,AdultPeriodontics(otherthanmaintenance)AdultEndodontics(GroupDentalPlansonly)

$0‐$25 $0‐$25

MajorServicesCrowns&Casts,Prosthodontics,Endodontics,Periodontics(otherthanmaintenance,andOralSurgery

$0‐$350 $0‐$400

Orthodontia(Onlyforpre‐authorizedMedicallyNecessaryOrthodontia)

$0‐$350 N/A

IndividualDeductible(WaivedforDiagnosticandPreventive) $0 N/A

FamilyDeductible(WaivedforDiagnosticandPreventive) $0 N/A

OutofPocketMaximum(OOP)(perperson)

$350 N/A

OutofPocketMaximum(OOP)(2+children)

$700 N/A

AnnualMaximum None N/AOrthoLifetimeMaximum None N/AOfficeVisit(PerVisit) $0 $0WaitingPeriod None N/A*Benefitsareavailableforindividualsuptoage19**Benefitsareavailableforindividualsages19andover.

Benefitsareprovidediftheplandeterminestheservicestobemedicallynecessary.Eachindividualprocedurewithineachcategorylistedabove,andwhichiscoveredunderthePlanhasaspecificCopayment,whichisshownintheScheduleofBenefitsalongwithabenefitdescriptionandlimitations.TheExclusionsarealsolistedintheScheduleofBenefits.

HBEX-EOC-IP-CA-17

TableofContentsIntroduction.....................................................................................................................................................................................................................................2

UsingthisBooklet........................................................................................................................................................................................................2Welcome!AbouttheDentalPlan........................................................................................................................................................................2

LanguageAssistanceServices................................................................................................................................................................................................2InterpreterandTranslationServicesatNoChargetotheEnrollee...................................................................................................2SpeaktoaRepresentativeinYourPreferredLanguage..........................................................................................................................2FindaProviderWhoSpeaksYourLanguage.................................................................................................................................................2AssistanceFilingaGrievance.................................................................................................................................................................................2VitalDocuments............................................................................................................................................................................................................3ProviderOffice...............................................................................................................................................................................................................3

Definitions.........................................................................................................................................................................................................................................3Non‐CoveredServicesmeansadentalservicethatisnotacoveredbenefitunderthiscontract.....................................5

EnrolleeIdentificationCard.....................................................................................................................................................................................................6WhatistheAccessDentalIndividualDentalProgram?...........................................................................................................................................7EnrolleeRightsandResponsibilities..................................................................................................................................................................................7EligibilityandEnrollment.........................................................................................................................................................................................................8

Whoiseligibleforcoverage?..................................................................................................................................................................................8ServiceArea.....................................................................................................................................................................................................................8HowdoIenroll?............................................................................................................................................................................................................8Renewal,CancellationandTerminationofBenefits..................................................................................................................................8

HowtousetheAccessDentalProgram–ChoiceofDentist...................................................................................................................................9FacilitiesandLocations.............................................................................................................................................................................................9ChoosingaPrimaryCareDentalProvider.......................................................................................................................................................9SchedulingAppointments.....................................................................................................................................................................................10ProviderReimbursement.....................................................................................................................................................................................10

UrgentCare.....................................................................................................................................................................................................................................10EmergencyServices...................................................................................................................................................................................................................11SpecialistServices.......................................................................................................................................................................................................................12PreauthorizationandReferralstoSpecialists...........................................................................................................................................................12

RoutineReferrals...............................................................................................................................................……………………………………..12UrgentCareReferrals..............................................................................................................................................................................................12EmergencyCareReferrals....................................................................................................................................................................................12Notifications.................................................................................................................................................................................................................12

SpecialNeeds................................................................................................................................................................................................................................15AccessingCare..............................................................................................................................................................................................................................15FacilityAccessibility.................................................................................................................................................................................................................15WhatifIneedtochangeContractDentists?...............................................................................................................................................................15ContinuityofCare.......................................................................................................................................................................................................................16Benefits,LimitationsandExclusions................................................................................................................................................................................16CopaymentsandOtherCharges..........................................................................................................................................................................................16ObtainingaSecondOpinion..................................................................................................................................................................................................16ClaimsforReimbursement....................................................................................................................................................................................................17ProcessingPolicies.....................................................................................................................................................................................................................17EnrolleeComplaintProcedure.............................................................................................................................................................................................17EntireContract.............................................................................................................................................................................................................................18PublicPolicyParticipationbyEnrollees.........................................................................................................................................................................18GoverningLaw..............................................................................................................................................................................................................................19CoordinationofBenefits..........................................................................................................................................................................................................19GeneralProvisions......................................................................................................................................................................................................................20

NoticeandProofofClaim......................................................................................................................................................................................20EligibilityofMedicaidNotConsidered...........................................................................................................................................................20Incontestability...........................................................................................................................................................................................................20

ConfidentialityofDentalRecords.......................................................................................................................................................................................20OrganandTissueDonation...................................................................................................................................................................................................20PrivacyPractices..........................................................................................................................................................................................................................20ATTACHMENTA–NoticeofPrivacyPractices...........................................................................................................................................................23ATTACHMENTB–AuthorizationtoUse&DiscloseHealthInformation.....................................................................................................26

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Introduction

UsingthisBooklet

This booklet, called the Combined Evidence of Coverage and Disclosure Form/ Contract, containsdetailedinformationaboutBenefits,howtoobtainBenefits,andyourrightsandresponsibilities.Pleasereadthisbookletcarefullyandkeepitonhandforfuturereference.

Throughoutthisbooklet,“you,”“your,”and“Member”referstotheindividualEnrollee(s)intheplan.“We,” “Us,” and “Our” always refers to AccessDental. “Primary CareDentist” refers to the licenseddentist who is responsible for providing initial and primary care dental services to Enrollee(s),maintains the continuity of patient care, initiates referrals for specialist care, and coordinates theprovisionofallBenefitsforyouinaccordancewiththispolicy.

Welcome!AbouttheDentalPlan

Access Dental Plan (“Access Dental” or “the Plan”) is a prepaid dental plan. The Plan providescomprehensivedentalcoverageforEnrollees.ThePlanhasapanelofdentistsfromwhomyouselecttoreceivenecessarydentalcare.ManydentalprocedurescoveredrequirenoCopayment.Inaddition,thePlan hasmade the process of dental treatment convenient by eliminating cumbersome claim formswhen an Enrollee receives routine care from his or her Primary Care Dentist. Please review theinformation included in this document and contact your Primary Care Dentist to arrange your firstappointment.Ifyoumove,youmustcontactCustomerServicetoselectanewPrimaryCareDentistifyoupreferadentistthatisclosertoyournewhome. IfyoutemporarilymoveoutsideoftheServiceArea,suchastoattendschool,youmayremainwiththePlanandreceivecarefromyourPrimaryCareDentistwhenreturningtotheServiceArea.Ifyoumovetemporarily,youmayobtainEmergencyCareorUrgentCarefromanydentistandwewillreimbursecoveredservices,lessapplicablecopayments,asdescribed in the Emergency Care or Urgent Care Section. If you have any questions, please callCustomerServicetollfreeat(844)561‐5600.

LanguageAssistanceServices

AccessDental’sLanguageAssistanceProgramprovideslanguageassistanceservicesforourmemberswithanon‐Englishpreferredlanguageatnocharge.

InterpreterandTranslationServicesatNoChargetotheEnrollee

Enrollees can call Access Dental’s Customer Service Line at (844) 561‐5600 to access these freeservices.TDD/TTYforthehearingimpairedisavailablethrough(800)735‐2929.

SpeaktoaRepresentativeinYourPreferredLanguage

CustomerServiceRepresentativescanansweryourquestionsregardingbenefits,eligibility,andhowtouseyourdentalplan.

FindaProviderWhoSpeaksYourLanguage

CustomerServiceRepresentativescanhelpyoufindaproviderwhospeaksyourlanguageorwhohasaninterpreteravailable.Ifyoucannotlocateaprovidertomeetyourlanguageneeds,youcanrequesttohaveaninterpreteravailablefordiscussionsofdentalinformationatnocharge.

AssistanceFilingaGrievance

YouhavetherighttofileagrievancebymailorinpersonwithAccessDentalorobtainassistancefromtheDepartmentofManagedHealthCare(DMHC).Youmayrequesttospeakwitharepresentativeinaspecific language. Theprocess for filing a grievance isdescribedunder theGrievances andAppealssectionofthisbooklet.

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VitalDocuments

Thisnoticeofavailable languageassistanceserviceswillbe includedwithallvitaldocumentssenttotheEnrollee. Standardizedvitaldocumentswillbetranslated intoSpanishatnochargetoenrollees.Forvitaldocumentsthatarenotstandardized,butwhichcontainenrollee‐specificinformation,AccessDental shall provide the requested translation within 21 days of the receipt of the request fortranslation. It can be obtained by calling Customer Service at (844) 561‐5600 (TDD/TTY for thehearingimpairedat(800)735‐2929).

Standardizedvitaldocuments:

Welcomepacket BenefitandCopaymentSchedule ExclusionsandLimitations GrievanceForm EnrolleenotificationofchangesinPrimaryCareDentist PrivacyNotices HIPAArelatedforms

ProviderOffice

Ifyouhaveapreferred languageother thanEnglish,please informyourPrimaryCareDentist. YourPrimaryCareDentistwillworkwithAccessDentaltoprovidelanguageassistanceservicestoyouatnocharge.YoumayrequestfacetofaceinterpretingserviceforanappointmentbycallingAccessDental’sCustomer Service Department. Access Dental will provide timely access to Language AssistanceServices.

Definitions

AsusedinthisCombinedEvidenceofCoverageandDisclosureForm/Contract:

Acute Conditionmeans a medical condition that involves a sudden onset of symptoms due to anillness,injury,orothermedicalproblemthatrequirespromptmedicalattentionandthathasalimitedduration.

Applicant means the individual responsible for contracting to obtain dental Benefits for his/herChildrenastheprimaryEnrollee.YOUorYOURreferstotheApplicant’sChildren.

BenefitsmeanthosedentalservicesthatareprovidedunderthetermsofthisContractanddescribedinthisbooklet.

Benefits(CoveredServices)meansdentalservicesandsuppliesthatanEnrolleeisentitletoreceivepursuanttothetermsofthisContract.Aserviceisnotabenefit(evenifdescribedasaCoveredService)orbenefitinthisbookletifitisnotDentallyNecessary,orifitisnotprovidedbyanAccessDentalPlanproviderwithauthorizationasrequired.

Child(ren)meanstheApplicant’sChild(ren),includinganynatural,adopted,orstep‐children,newbornChildren,oranyotherChild(ren)asdescribedinthe“Eligibility&Enrollment”sectionofthisCombinedEvidenceofCoverageandDisclosureForm/Contract.

ComplaintmeansawrittenororalexpressionofdissatisfactionregardingthePlanand/oraprovider,including quality of care concerns, and shall include a grievance, complaint, dispute, request forreconsideration, or appealmadeby anEnrollee or theEnrollee’s representative. Where thePlan isunabletodistinguishbetweenaGrievanceandaninquiry,itshallbeconsideredaGrievance.Examplesofacomplaintinclude:

Youcan’tgetaserviceortreatmentthatyouneed;

Yourplandeniesaserviceandsaysitisnotmedicallynecessary;

Youhavetowaittoolongforanappointment;

Youreceivedpoorcareorweretreatedrudely;

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Yourplandoesnotreimburseemergencyorurgentcarethatyouhadtopayfor;

Yougetabillthatyoubelieveyoushouldnothavetopay.

Contract means this agreement between Access Dental and the Applicant including theEnrollmentForm,theattachedschedules,andanyappendices,endorsementsorriders. ThisContractconstitutestheentireagreementbetweentheparties.

ContractDentistmeansaDentistwhoprovidesservicesingeneraldentistry,andwhohasagreedtoprovideBenefitsunderthisProgram.

Contract Orthodontist means a Dentist who specializes in orthodontics, and who has agreed toprovideBenefitsunderthisProgram.

ContractSpecialistmeansaDentistwhoprovidesSpecialistServices,andwhohasagreedtoprovideBenefitstoEnrolleesunderthisProgram.

ContractTermmeans the one‐year period starting on the Effective Date and each annual renewalperiodduringwhichtheContractremainsineffect.

CoordinationofBenefits (COB)means the provision that applieswhen an Enrollee is covered bymorethanoneplanatthesametime.COBdesignatestheorderinwhichplansaretopaybenefits.

Copayment means the amount listed in the Schedule ofBenefits paid by an Enrollee to a ContractDentistorContractSpecialistfortheBenefitsprovidedunderthisPlan.EnrolleesareresponsibleforpaymentofallCopaymentsatthetimetreatmentisreceived.

DentalPlan(Plan)meansAccessDentalPlan.

Dentally Necessarymeans necessary and appropriate dental care for the diagnosis according toprofessionalstandardsofpracticegenerallyacceptedandprovidedinthecommunity.Thefactthatadentistmay prescribe, order, recommend or approve a service or supply does notmake itDentallyNecessary.ThefactthataserviceorsupplyisDentallyNecessarydoesnot,inandofitself,makeitaCoveredService;however,allCoveredServicesmustalsobeDentallyNecessary.

DentistmeansadulylicensedDentistlegallyentitledtopracticedentistryatthetimeandinthestateorjurisdictioninwhichservicesareperformed.

DHMOmeansDentalHealthMaintenanceOrganization.

EffectiveDatemeansthefirstdayofthemonthfollowingAccessDental’stimelyreceiptofpremiumandtheEnrollmentandPaymentAuthorizationForm.

Emergency Care (or Emergency Service) means a dental condition, including severe pain,manifestingitselfbyacutesymptomsofsufficientseveritysuchthattheabsenceofimmediatemedicalattentioncouldreasonablybeexpectedtoresultinanyofthefollowing:

PlacingtheEnrollee’sdentalhealthinseriousjeopardy;or

CausingseriousimpairmenttotheEnrollee’sdentalfunctions;or

CausingseriousdysfunctionofanyoftheEnrollee’sbodilyorgansorparts.

Enrollee(orMember)meansapersonenrolledtoreceiveBenefits.

ExclusionmeansanydentaltreatmentorserviceforwhichthePlanoffersnocoverage.

Experimental or Investigational Servicemeans any treatment, therapy, procedure, drug or drugusage, facility or facility usage, equipment or equipment usage, device or device usage, or supplieswhicharenotrecognizedasbeinginaccordancewithgenerallyacceptedprofessionaldentalstandards,or if safety and efficacy have not been determined for use in the treatment of a particular dentalconditionforwhichtheitemorserviceinquestionisrecommendedorprescribed.

GrievancemeansawrittenororalexpressionofdissatisfactionregardingthePlanand/oraprovider,includingqualityofcareconcerns,andshallincludeacomplaint,dispute,requestforreconsiderationor

5 HBEX-EOC-IP-CA-17

appealmadebyanEnrolleeortheEnrollee’srepresentative. WherethePlanisunabletodistinguishbetweenaGrievanceandaninquiry,itshallbeconsideredaGrievance.

InterpretingServicemeansAccessDental’scontractedvendorwhichprovidesphoneandface‐to‐facelanguageinterpretingservices.

Language Assistance Services means translation of standardized and Enrollee‐specific vitaldocumentsintothresholdlanguagesandinterpretationservicesatallpointsofcontact.

Limited EnglishProficient or LEP Enrolleemeans an Enrollee who has an inability or a limitedabilitytospeak,read,write,orunderstandtheEnglishlanguageatalevelthatpermitsthatindividualtointeracteffectivelywithhealthcareprovidersorplanemployees.

Non‐Participating or Non‐Contracted Providermeans a provider who has not contracted withAccessDentaltoprovideservicestoEnrollees.

Non‐CoveredServicesmeansadentalservicethatisnotacoveredbenefitunderthiscontract.

IMPORTANT: Ifyouopt toreceivedentalservices thatarenotcoveredservicesunder thisplan,aparticipatingdentalprovidermaychargeyouhisorherusualandcustomaryrateforthoseservices.Prior toprovidingapatientwithdental services thatarenota coveredbenefit, thedentist shouldprovidetothepatientatreatmentplanthatincludeseachanticipatedservicetobeprovidedandtheestimatedcostofeachservice.IfyouwouldlikemoreinformationaboutdentalcoverageoptionsyoumaycallthePlan’sMemberServiceat1(844)561‐5600.

OptionalBenefitmeansadentalbenefitthatyouchoosetohaveupgraded.Forexample,whenafillingwouldcorrectthetoothbutyouchoosetohaveafullcrowninstead.

OutofNetworkmeanstreatmentbyaDentistwhohasnotsignedanagreementwithAccessDentaltoprovideBenefitsunderthetermsofthisContract.

OutofPocketMaximummeansthemaximumamountofmoneythatapediatricenrolleemustpayforbenefitsduringacalendaryear.

OutofPocketMaximumappliesonlytoEssentialHealthBenefits(EHB)forPediatricEnrollees

Ifmorethanonepediatricenrolleeiscoveredunderthecontract,thefinancialobligationforbenefitsisnotmorethantheOutofPocketMaximumsformultiplepediatricenrollees.

Cost sharing paymentsmadeby each individual child for in‐network covered services accrue to thechild'sout‐of‐pocketmaximum.Once the child's individual out‐of‐pocket maximum has been reached, the plan pays all costs forcoveredservicesforthatchild.

Inaplanwithtwoormorechildren,costsharingpaymentsmadebyeachindividualchildforout‐of‐networkcoveredservicescontributetothefamilyout‐of‐networkdeductible,ifapplicable,anddonotaccumulate to the family out‐of‐pocket maximum. Participating or ContractedProvidermeans adentistordentalfacilitylicensedtoprovideCoveredServiceswhoorwhichatthetimecareisrenderedtoanEnrolleehasacontractineffectwithAccessDentaltoprovideCoveredServicestoEnrollees.

Preauthorization(orPriorAuthorization)meanstheprocessbywhichAccessDentaldeterminesifaprocedureortreatmentisareferablebenefitundertheEnrollee’splan.

PremiummeanstheamountpayableasprovidedinthisContract.

Primarymeans,forthepurposeofCoordinationofBenefits,thedentalplandeterminedtobetheplanwhichmustpayforBenefitsfirstwhentheEnrolleeiscoveredbyUsandanotherplan.

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PrimaryCareDentistmeansaduly licenseddentist legallyentitledtopracticedentistryatthetimeand in the state or jurisdiction inwhich services are performed. A dentist, who is responsible forproviding initial and primary care to Enrollees, maintains the continuity of patient care, initiatesreferralforspecialistcare,andcoordinatestheprovisionofallBenefitstoEnrolleesinaccordancewiththeContract.

ProtectedHealth Information (PHI)means informationabout you that can reasonablybeused toidentifyyouandthatrelatestoyourpast,present,orfuturephysicalormentalhealthorcondition,theprovisionofhealthcaretoyouorthepaymentforthatcare.

ProviderDirectorymeansthedirectoryofContractedDentistsforyourPlan.

Reasonable means that an Enrollee exercises prudent judgment in determining that a dentalemergency exists and makes at least one attempt to contact his/her Contract Dentist to obtainEmergencyServicesand,intheeventtheDentistisnotavailable,makesatleastoneattempttocontactAccessDentalforassistancebeforeseekingcarefromaNon‐Contractedprovider..

SecondOpinion(orSecondAttempt)meanstheprocessofseekinganevaluationbyanotherdentist,doctororsurgeontoconfirmthediagnosisandtreatmentplanofaPrimaryCareDentistortoofferanalternativediagnosisand/ortreatmentapproach.

ServiceAreameansthegeographicareaintheStateofCaliforniawheretheDepartmentofManagedHealthCareServices(DMHC)hasauthorizedAccessDentaltoprovideDentalHMOservices.

Special Health Care Need means a physical or mental impairment, limitation or condition thatsubstantiallyinterfereswithanEnrollee’sabilitytoobtainBenefits.ExamplesofsuchaSpecialHealthCare Need are 1) the Enrollee’s inability to obtain access to the assigned Contract Dentist’s facilitybecause of a physical disability and 2) the Enrollee’s inability to complywith the ContractDentist’sinstructionsduringexaminationortreatmentbecauseofphysicaldisabilityormentalincapacity.

Specialist(Specialty)ServicesmeanservicesperformedbyaDentistwhospecializesinthepracticeoforalsurgery,endodontics,periodontics,orthodonticsorpediatricdentistry.SpecialistServicesmustbepreauthorizedinwritingbyAccessDental.

Treatment inProgressmeansanysingledentalprocedure,asdefinedby theCDTCode,whichhasbeenstartedwhiletheEnrolleewaseligibletoreceiveBenefits,andforwhichmultipleappointmentsare necessary to complete the procedure whether or not the Enrollee continues to be eligible forBenefitsunderAccessDental.Examplesinclude:teeththathavebeenpreparedforcrowns,rootcanalswhereaworkinglengthhasbeenestablished,fullorpartialdenturesforwhichanimpressionhasbeentakenandorthodonticswhenbandshavebeenplacedandtoothmovementhasbegun.

Urgent Care means dental care needed to prevent serious deterioration of an Enrollee’s healthresulting fromunforeseen illness or injury forwhich treatment cannot be delayed, includingOut‐ofAreadentalservicesthatcannotbedelayeduntiltheEnrolleereturnstotheServiceArea.

UsualFeemeans the fee usually charged by the Provider to his or her private patients for a givenserviceormaterial.

We,UsorOurmeansAccessDentalPlan.

YouorYourmeansthemember,enrolleeorApplicant’sChildren.

EnrolleeIdentificationCard

You will be given an Enrollee Identification Card. This card contains important information forobtainingservices.IfyouhavenotreceivedyourcardorifyouhavelostyourEnrolleeIdentificationCard,pleasecallusat(844)561‐5600(TDD/TTYforthehearingimpairedat(800)735‐2929)andwewillsendyouanewcard. PleaseshowyourEnrolleeIdentificationCardtoyourproviderwhenyoureceivedentalcare.

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OnlytheEnrolleeisauthorizedtoobtaindentalservicesusinghisorherEnrolleeIdentificationCard.Ifa card is used by or for an individual other than the Enrollee, that individualwill be billed for theserviceheorshereceives.Additionally,ifyouletsomeoneelseuseyourEnrolleeIdentificationCard,wemaynotbeabletokeepyouinOurplan.

WhatistheAccessDentalIndividualDentalProgram?

TheAccessDental IndividualDentalProgram includes commercial andexchange certifiedplans.ForexampleourAccessDentalChildren’sDentalHMOplanwhichprovidescomprehensivedentalcaretochildrenundertheageof19tosatisfythepediatricessentialhealthbenefit,whichisrequiredundertheAffordableCareAct. AccessDental has a convenient networkof ContractedDentists in the State ofCalifornia.TheseDentistsarescreenedtoensurethatOurstandardsofquality,accessandsafetyaremaintained. The network is composed of established dental professionals. When you visit yourassigned Primary Care Dentist, you pay only the applicable Copayment for Benefits. There are nodeductibles,lifetimemaximumsorclaimforms.Plansinthisprogramincludeallages.

EnrolleeRightsandResponsibilities

AsanAccessDentalDHMOmember,youhavetherightto:

Betreatedwithrespectanddignity; ChooseyourPrimaryCareDentistfromOurProviderDirectory; Getappointmentswithinareasonableamountoftime Participateincandiddiscussionsanddecisionsaboutyourdentalcareneeds,includingappropriate

orDentallyNecessarytreatmentoptionsforyourcondition(s),regardlessofcostorregardlessofwhetherthetreatmentiscoveredbythePlan;

Haveyourdentalrecordskeptconfidential.ThismeansthatWewillnotshareyourdentalcareinformationwithoutyourwrittenapproval,unlessitisrequiredbylaw.

VoiceyourconcernsaboutthePlan,oraboutdentalservicesyoureceivedtoAccessDental. ReceiveinformationaboutAccessDentalPlan,OurservicesandOurproviders; Makerecommendationsaboutyourrightsandresponsibilities. Seeyourdentalrecords. GetservicesfromprovidersoutsideofOurnetworkinanemergency. Requestaninterpreteratnochargetoyou. Useinterpreterswhoarenotyourfamilymembersorfriends. ReceiveEnrolleematerialstranslatedintoyourlanguage. Fileacomplaintifyourlinguisticneedsarenotmet.Yourresponsibilitiesareto:

GiveyourprovidersandAccessDentalcorrectinformation. Understandyouroralhealthcareneedsandanydentalproblem(s)andparticipateindeveloping

treatmentgoals,asmuchaspossible,withyourprovider. Askquestionsaboutanydentalconditionmakecertainthattheexplanationsandinstructionsare

understandable. Makeandkeepdentalappointments.Youshouldinformyourprovideratleast24hoursinadvance

whenanappointmentmustbecancelled. HelpAccessDentalmaintainaccurateandcurrentrecordsbyprovidingtimelyinformation

regardingchangesinaddress,familystatus,andotherhealthcarecoverage. NotifyAccessDentalassoonaspossibleifaproviderbillsyouinappropriatelyorifyouhavea

complaint. TreatallAccessDentalpersonnelandprovidersrespectfullyandcourteously.

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EligibilityandEnrollment

Whoiseligibleforcoverage?

You, if you are over the age of 19 and live orwork in theAccessDentalHMO service area,regardlessofwhetheryouhaveachild.

Yourdependents,definedeligibleasthosewholiveorworkintheAccessDentalHMOservicearea:

o YourlawfulSpouseorDomesticPartnero Yourunmarriedchildrenorgrandchildrenuptoage26forwhomYouprovidecare,

includingadoptedchildren,step‐children,orotherchildrenforwhomYouarerequiredtoprovidedentalcarepursuanttoacourtoradministrativeorder.Anyadditionalrequirements,e.g.full‐timestudents.

o Yourchildrenwhoareincapableofself‐sustainingemploymentbecauseofamentalorphysicalhandicap,illness,orconditionandarechieflydependentuponYouforsupportandmaintenance.

Coveragewillbeginforyouandyourenrolledchildrenonthefirstdayofthemonthfollowingthedateyourpremiumpaymentisreceived.

ServiceArea

TheServiceAreaisthegeographicalareainwhichAccessDentalhasapanelofContractDentistsandContractSpecialistswhohaveagreedtoprovidecaretoAccessDentalEnrollees. Toenroll inAccessDental, you or the Applicantmust reside, live orwork in the Service Area and the permanent legalresidenceofanyenrolledChild(ren)mustalsobeintheServiceArea.

HowdoIenroll?

First,pleasereadalltheinformationcontainedinthisContract(particularlytheScheduleofBenefitsandLimitations and Exclusions). This way you will know what procedures are covered and what yourCopaymentsandPremiumwillbe.Second,fromthenetworkdirectory,chooseadentalfacilitythatisconvenient for you and your family’s treatment. Third, complete the Enrollment and PaymentAuthorizationFormandindicatewhichPrimaryCareDentistyouhavechosen.

Renewal,CancellationandTerminationofBenefits

Terminationfornon‐paymentofpremium

IftherequiredPremiumisnotpaid,yourcoveragemaybeterminatedpriortotheendoftheContractTerm. If any applicable Premium payment due from you is not paid timely, your benefits may becancellednotlessthan30daysafterthelastdayofpaidcoverage.

AGracePeriodofthreeconsecutivemonthswillbegivenifyouarereceivingadvancepaymentsofthepremiumtaxcreditandhavepreviouslypaidatleastonefullmonth’spremiumtoAccessDentalduringthebenefityear.AccessDentalwillpayallappropriateclaimsforservicesduringthefirstmonthoftheGracePeriodandmaypendclaimsforservicesrenderedtoyouduringthesecondandthirdmonthsoftheGracePeriod.Paymentmustbereceivedpriortotheendofthegraceperiodtoreinstateindividualtocoverage.ReceiptbyAccessDentalof theproperpremiumpaymentafter cancellationof thecontract fornon‐paymentshallreinstatethecontractasthoughithadneverbeencancelledifsuchpaymentisreceivedonorbeforetheduedateofthesucceedingpayment.

Enrollmentmaybecancelled forreasonsother thannonpaymentofPremium,upon30dayswrittennotice if:Wedemonstrate thatyou committed fraudoran intentionalmisrepresentationofmaterialfactunderthetermsofthiscontract.IfWeintendtorescindthecontractbecauseWecandemonstratethatyoucommittedfraudoranintentionalmisrepresentationofmaterialfactunderthiscontract,youwill receive a thirty (30)daynoticeprior to the effectivedateof rescission. In addition, youwill benotifiedofyourrighttoappealourdecision.

9 HBEX-EOC-IP-CA-17

CoverageforanEnrolleewillterminateasofthedateenrollmentiscancelledunderthetermsofthisCombinedEvidenceofCoverageandDisclosureForm/Contract.However,wewillcontinuetoprovideBenefitsforcompletionofanytreatmentinprogress(lessanyapplicableCopayment).An Enrollee who believes that enrollment has been canceled or not renewed because of dentalconditionortheneedfordentalcareorimproperlycancelled,rescindedornotrenewedmayrequestareviewof thecancellationby theDirectorof theDepartmentofManagedHealthCareof theStateofCalifornia.PleaserefertoEnrolleeComplaintProceduresectionofthisbooklet.

HowtousetheAccessDentalProgram–ChoiceofDentist

To access services in this Program, you must select a Primary Care Dentist from the list of dentalfacilitiesfurnishedwiththisContract.Iftheselectedfacilityisnotavailable,non‐contractedorclosedtofurtherenrollment,AccessDentalreservestherighttoassignyoutoanotherdentalofficethatisascloseaspossibletoyourresidence.YoumaycalltheCustomerServiceDepartmenttoselectorchangetheassignmentofaPrimaryCareDentistatanytime,foraneffectivedateofthechangeonthefirstofthe followingmonth after you enroll in theProgram. Youmust indicate thePrimaryCareDentist’snameandfacilityID#ontheEnrollmentandPaymentAuthorizationForm.Youmayobtaintreatmentfromanycontractdentistatthatsamefacility.Youmaychoosedifferentprimarycaredentistsfromthelistofdentalfacilitiesfurnishedwiththiscontract.

Shortly after enrollment, you will receive a Access Dental membership packet that tells you theEffectivedateofyourcoverage.ThepacketwillalsoshowtheaddressandtelephonenumberofyourPrimaryCareDentist. YoumayobtaincovereddentalservicesanytimeafteryourEffectiveDate.Tomakeanappointment,simplycallyourPrimaryCareDentist’sfacilityandidentifyyourselfasaAccessDentalEnrollee. Initialappointmentsshouldbescheduledwithin threeweeksunlessaspecific timehasbeenrequested.InquiriesregardingavailabilityofappointmentsandaccessibilityofPrimaryCareDentistsshouldbedirectedtotheCustomerServicedepartmentat(844)561‐5600.

YOUMUST GO TO YOUR ASSIGNED PRIMARY CARE DENTIST TO OBTAIN BENEFITS EXCEPT FOREMERGENCY SERVICESOR SPECIALIST SERVICES PREAUTHORIZEDBYUS AS DESCRIBEDBELOW.ANYOTHERTREATMENTISNOTCOVEREDUNDERTHISPROGRAM.

FacilitiesandLocations

PLEASEREADTHEFOLLOWINGINFORMATIONSOYOUWILLKNOWFROMWHOMORWHATGROUPOFPROVIDERSDENTALCAREMAYBEOBTAINED.

ThePlan’sPrimaryCareDentistsarelocatedclosetowhereyouortheApplicantworkorlive.

YoumayobtainalistofAccessDental’sContractedDentistsandtheirhoursofavailabilitybycallingUsat(844)561‐5600.AlistofContractedDentistscanalsobefoundonlineatwww.premierlife.com.

ChoosingaPrimaryCareDentalProvider

EnrolleesmustselectaPrimaryCareDentistfromthelistofproviderslistedintheProviderDirectory.TheEnrolleeshouldindicatehis/herchoiceofPrimaryCareDentistontheenrollmentform.EnrolleesfromthesamefamilymayselectdifferentPrimaryCareDentists.EachEnrollee’sPrimaryCareDentist(incoordinationwiththePlan)isresponsibleforcoordinationoftheEnrollee’sdentalcare.ExceptforEmergencyDentalCare,anyservicesandsuppliesobtainedfromaNon‐ParticipatingProviderotherthantheEnrollee’sPrimaryCareDentistwithoutanapprovedreferralbyAccessDentalwillnotbepaidbyAccessDental. Toreceive information,assistance,andtheofficehoursofyourPrimaryCareDentist,contactCustomerServiceat(844)561‐5600duringregularbusinesshours.

You should not receive a bill for a Covered Service from a Participating Provider (except forCopayments). However, ifyoudoreceiveabill,pleasecontactCustomerServiceat (844)561‐5600.We will reimburse an Enrollee for Emergency Care or Urgent Care services (less any applicableCopayment). You will not be responsible for payments owed by Access Dental to ParticipatingProviders. However,youwillbe liable forthecostsofservicestoNon‐ParticipatingProviders ifyoureceivecarewithoutPreauthorization(unlessservicesarenecessaryasaresultofanEmergencyCare

10 HBEX-EOC-IP-CA-17

condition).Ifyouchoosetoreceiveservices,whicharenotCoveredServices,youwillberesponsibleforthoseservices.

SchedulingAppointments

ParticipatingDentistsareopenduringnormalbusinesshoursandsomeofficesareopenSaturdayonalimitedbasis. Ifyoucannotkeepyourscheduledappointment,youarerequiredtonotify thedentalofficeatleast24hoursinadvance. AfeemaybechargedbyyourPrimaryCareDentistforfailuretocancelanappointmentwithout24hourspriornotification. Call thePrimaryCareDentistdirectly toscheduleanappointment. Ifyourequirespecialtycare,yourPrimaryCareDentistwillcontactUstoarrangeforsuchcare.

Appointmentsforroutineandpreventivecareshallnotexceed4weeksfromthedateoftherequestforanappointment.WaittimeintheParticipatingProvider’sofficeshallnotexceed30minutes.

Appointments for initial specialist consultation shall not exceed six weeks from the request for anappointment.

ProviderReimbursement

Bystatute,everycontractbetweenAccessDentalanditsprovidersstatethat,intheeventAccessDentalfailstopaytheprovider,youwillnotbeliabletotheproviderforanysumsowedbytheplan.IfyoureceiveservicesfromaNon‐Contractedprovider,youmaybeliabletotheNon‐Contractedproviderforthecostofservicesrendered.IfyoureceiveemergencyservicesfromaNon‐ContractedProvider,youare entitled to reimbursement, subject to the Emergency Services Reimbursement provision of thisCombinedEvidenceofCoverageandDisclosureForm/Contract.

ParticipatingDentistsarecompensated througha combinationofpermember,permonthpayments(or “capitated” basis) and may receive an additional fee for certain procedures performed(supplemental payments). Contracted Specialists are compensated on a discounted fee for servicebasis.

Foradditional information,youmaycontactAccessDentalat (844)561‐5600orspeakdirectlywithyourprovider.

IMPORTANT: If you opt to receive dental services that are not covered services under this plan, aParticipatingDentalProvidermaychargeyouhisorherusualandcustomaryrateforthoseservices.Prior toprovidingapatientwithdental services that arenot a coveredbenefit, theprovider shouldprovidetothepatientatreatmentplanthatincludeseachanticipatedservicetobeprovidedandtheestimatedcostofeachservice.Ifyouwouldlikemoreinformationaboutdentalcoverageoptions,youmay call Member Services at (844) 561‐5600 or your insurance broker. To fully understand yourcoverage,youmaywishtocarefullyreviewthisContract.

UrgentCare

UrgentCareservicesareservicesneededtopreventseriousdeteriorationofyourhealthresultingfromanunforeseen illnessor injury forwhichtreatmentcannotbedelayed. ThePlancoversUrgentCareservicesanytimeyouareoutsideOurServiceAreaoronnightsandweekendswhenyouareinsideOurServiceArea.TobecoveredbythePlan,theUrgentCareservicemustbeneededbecausetheillnessorinjurywillbecomemuchmoreserious,ifyouwaitforanappointmentwithyourPrimaryCareDentist.Onyourfirstvisit,talktoyourPrimaryCareDentistaboutwhatheorshewantsyoutodowhentheofficeisclosedandyoufeelUrgentCaremaybeneeded.To obtain Urgent Care when you are inside the Plan’s Service Area on nights and weekends, theMember must notify his or her Primary Care Dentist, describe the Urgent Condition, and make anappointment to seehisorherPrimaryCareDentistwithin24hours. If thePrimaryCareDentist isunabletoseetheMemberwithinthe24‐hourperiod,theMembermustimmediatelycontactthePlanat(844)561‐5600andthePlanwillarrangealternativedentalcare.


ToobtainUrgentCarewhenyouareoutsidethePlan’sServiceArea,theMembershouldseekcarefromanyNon‐ParticipatingProvider. Services that donotmeet thedefinition ofUrgent Carewill not becoverediftreatmentwasprovidedbyaNon‐ParticipatingProvider.Non‐ParticipatingProvidersmayrequiretheMembertomakeimmediatefullpaymentforservicesormayallowtheMembertopayanyapplicableCopaymentsandbillthePlanfortheunpaidbalance.IftheMemberhastopayanyportionofthebill,thePlanwillreimbursetheMemberforservicesthatmeetthedefinitionofEmergencyCareorUrgentCareasdefinedabove.IftheMemberpaysabill,acopyofthebillorinvoicefromthedentistwhoprovidedthecareandabriefexplanationofthecircumstancesthatgaverisetotheneededdentalcareshouldbesubmittedtothefollowingaddress:AccessDentalPlan,Attention:ClaimsDepartment,P.O.Box:659005,Sacramento,CA95865‐9005.BenefitsforUrgentCarenotprovidedbythePrimaryCareDentistarelimitedtoamaximumof$100.00perincident,lesstheapplicableCopayment.Ifthemaximumisexceeded,ortheaboveconditionsarenotmet,theEligibleenrolleeisresponsibleforanychargesforservicesbyaproviderotherthantheirPrimaryCareDentist.If you seek Urgent Care from a provider locatedmore than 25miles away from your participatingprovider,youwillreceiveemergencybenefitscoverageuptoamaximumof$100,lessanyapplicablecopayments.IfyoureceiveUrgentCaredentalservices,youmayberequiredtopaytheproviderwhorenderedsuchemergencydentalserviceandsubmitaclaimtothePlanforareimbursementdetermination. ClaimsforEmergencyCareshouldbesenttoAccessDentalPlanwithin180daysoftheendoftreatment.Validclaimsreceivedafterthe180‐dayperiodwillbereviewediftheEligibleEnrolleecanshowthatitwasnotreasonablypossibletosubmittheclaimwithinthattimeDecisionsrelatingtopaymentordenialofthereimbursementrequestwillbemadewithinthirty(30)businessdaysofthedateofallinformationreasonablyrequiredtorendersuchdecisionisreceivedbythePlan.OncetheMemberhasreceivedUrgentCare,theMembermustcontacthisorherPrimaryCareDentist(if theMember'sownPrimaryCareDentistdidnotperformthedentalcare)forfollow‐upcare. TheMemberwillreceiveallfollow‐upcarefromhisorherownPrimaryCareDentist.

EmergencyServices

Your assigned Primary Care Dentist maintains a 24‐hour Emergency Services system seven days aweek.IfEmergencyServices(seedefinitions:“EmergencyCare”)areneeded,youshouldcontactyourPrimary CareDentistwhenever possible. Benefits forEmergency Services by any otherDentist arelimitedtonecessarycaretostabilizetheconditionand/orproviderpalliativereliefwhenyou:

1) have made a Reasonable attempt to contact your Primary Care Dentist and the Primary CareDentistisunavailableorunabletoseeyouwithin24hoursofmakingcontact;or

2) havemadeareasonableattempttocontactAccessDentalpriortoreceivingEmergencyServices,oritisReasonableforyoutoaccessEmergencyServiceswithoutpriorcontactwithAccessDental;or

3) reasonablybelievethatyourconditionmakesitdentally/medicallyinappropriatetotraveltothePrimaryCareDentisttoreceiveEmergencyServices.

BenefitsforemergencyservicesnotprovidedbythePrimaryCareDentistarelimitedtoamaximumof$100peremergency,perenrollee,lesstheapplicableCopayment.Ifthemaximumisexceeded,youareresponsibleforanychargesforservicesbyaDentistotherthanyourPrimaryCareDentist.

If you seek emergencydental services fromaprovider locatedmore than25miles away fromyourparticipatingprovider,youwillreceiveemergencybenefitscoverageuptoamaximumof$100,lessanyapplicablecopayments.

Ifyoureceiveemergencydentalservices,youmayberequiredtopaytheproviderwhorenderedsuchemergencydentalserviceandsubmitaclaimtothePlanforareimbursementdetermination. Claims


forEmergencyCare shouldbe sent toAccessDentalwithin180days of the endof treatment. Validclaimsreceivedafterthe180‐dayperiodwillbereviewediftheEligibleEnrolleecanshowthatitwasnotreasonablypossibletosubmittheclaimwithinthattime.

SpecialistServices

Specialist Services for oral surgery, endodontics, periodontics, or pediatric dentistry, must be 1)referred by the assignedPrimary CareDentist, and 2) preauthorized inwriting by us. You pay thespecifiedCopayment(RefertoScheduleofBenefits).

IfyourequireSpecialistServicesandthereisnoContractSpecialisttoprovidetheseserviceswithin30miles of your home address, your assigned Contract Dentist must receive written Preauthorizationfrom Access Dental to refer you to an Out‐of‐Network specialist to provide the Specialist Services.Specialist Services performed by anOut‐of‐Network specialist that are not preauthorized by AccessDentalmaynotbecovered.

PreauthorizationandReferralstoSpecialists

SpecialtyCareReferrals

Duringthecourseof treatment,YourSelectedGeneralDentistmayencountersituations thatrequiretheservicesofaSpecialtyCareDentist.YourSelectedGeneralDentist isresponsible fordeterminingwhen the services of a Specialty Care Dentist are necessary. All referrals to Specialty Care DentistsrequireaSpecialtyCareReferral.

RoutineCare,UrgentandEmergencyReferralsTimeframes

RoutineCareReferralsareprocessedwithinfive(5)businessdaysfromthedatetherequestisreceivedinouroffice.Urgentcarereferralsareprocessedwithinseventy‐two(72)hoursorlessofthereceiptofthe necessary documentation. Copies of authorizations for regular referrals are sent to You, theSpecialty Care Dentist and Your Selected General Dentist. Emergency referrals are processedimmediately.

YouareencouragedtocontactYourSelectedGeneralDentisttoscheduleafollow‐upappointmentafterthecompletionofthetreatmentbytheSpecialtyCareDentist.IfYouhaveanyquestionsaboutSpecialtyCareReferrals,pleasecallAccessDentalbydialing(844)561‐5600.

Authorization,Modification,orDenialofServices

Decisions to approve, modify, or deny, based on dental necessity, prior to or concurrent with theprovisionofdental care services toYou shall bemadebyus in a timely fashionappropriate for thenature of Your condition, not to exceed five (5) business days from our receipt of the informationreasonablynecessaryandrequestedbyustomakethedetermination.Inthecaseofconcurrentreview,care shall not be discontinued until the enrollee's treating provider has been notified of the AccessDental’sdecisionandacareplanhasbeenagreeduponbythetreatingproviderthatisappropriateforthemedicalneedsofthatpatient.

UrgentRequests

IfYourconditionissuchthatYoufaceaimminentandseriousthreattoYourdentalhealthincluding,butnotlimitedto,thelossofmajordentalfunction,orifwaitinginaccordancewiththetimeframe

notedintheaboveparagraphcouldjeopardizeYourabilitytoregainmaximumfunction,ourdecisiontoapprove,modify, or deny referral requests by Your SelectedGeneralDentist prior to, or concurrentwith,theprovisionofdentalcareservicestoYoushallbemadeinatimelyfashionappropriateforthenature of Your condition, not to exceed seventy‐two (72) hours after the Plan’s receipt of theinformationreasonablynecessaryandrequestedbyustomakethedetermination.


WeshallinitiallynotifybytelephoneorfaxYourSelectedGeneralDentistofourdecisiontoapprove,modify,ordenyrequestsforreferralauthorizationwithintwenty‐four(24)hoursofourdecision.Wewill also immediately inform Your Selected General Dentist in writing of the decision to approve,modifyordenythereferral.Ifthereferralisapproved,wewillspecifyinthenoticethespecificdentalcareserviceapprovedandwewillspecifyinthenotice,theclearandconciseexplanationofthereasonsfor the decisions, the criteria or guideline used, and the clinical reasons for the decisions regardingdentalnecessity.Additionally,wewillincludethenameanddirecttelephonenumberofwhomadethedecision.

Ifwecannotapprove,modify,ordeny the request for authorizationwithin the timeframesspecifiedabovebecausewearenotinreceiptofalltheinformationreasonablynecessaryandrequested,becausewerequireconsultationbyanexpertreviewer,orbecauseweaskedforanadditionalexaminationortestbeperformeduponYou, thenwewill immediatelyupon theexpirationof the timeframesnotedabove,orassoonaswebecomeawarewewillnotmeetthosetimeframes,whicheveroccursfirst,notifyYourSelectedGeneralDentistandYou,inwriting,thatwecannotmakeadecisionwithintherequiredtimeframe and specify the information requested but not received, or the expert reviewer to beconsulted or the additional examinations or tests required. Once we receive all the informationreasonablynecessaryandrequested,wewillapprove,modify,ordenytherequestforauthorizationinatimelyfashionappropriateforthenatureofYourcondition,nottoexceedseventy‐two(72)hoursorfive(5)businessdays.

Informationregardingtheprocesses,criteriaandproceduresthatweusetoauthorize,modifyordenydentalservicesunderthebenefitsprovidedbyusareavailabletoYou,YourSelectedGeneralDentistandthepublicuponrequest.

SecondOpinion

Youmayrequestasecondopinionifthereareunansweredquestionsaboutdiagnosis,treatmentplans,and/or the results achieved by such dental treatment. In addition, Access Dental, or You or YourSelectedGeneralDentistmayalsorequestasecondopinion.There isnosecondopinionconsultationcharge.YouwillberesponsiblefortheofficevisitCo‐PaymentaslistedintheScheduleofBenefits.

Reasons a second opinionmay be provided or authorized shall include, but are not limited to, thefollowing:

• IfYouquestionthereasonablenessornecessityofrecommendedsurgicalprocedures;

• IfYouquestionadiagnosisorplanofcareforaconditionthatthreatenslossoflife,lossoflimb,loss of bodily function, or substantial impairment, including, but not limited to, a seriouschroniccondition;

• Iftheclinicalindicationsarenotclearorarecomplexandconfusing,adiagnosisisindoubtdueto conflicting test results, or the treating SelectedGeneralDentist is unable to diagnose thecondition,andtheEnrolleerequestsanadditionaldiagnosis;or

• IfthetreatmentplaninprogressisnotimprovingYoudentalconditionwithinanappropriateperiod of time given the diagnosis and plan of care, and You request a second opinionregardingthediagnosisorcontinuanceofthetreatment.

Requestsforsecondopinionsareprocessedwithinfive(5)businessdaysofourreceiptofsuchrequestexceptwhenanexpeditedsecondopinioniswarranted;inwhichcaseadecisionwillbemadeand

conveyedtoYouwithintwenty‐four(24)hours.Uponapproval,wewillcontacttheconsultingSelectedGeneralDentistandmakearrangementstoenableYoutoscheduleanappointment.


AllsecondopinionconsultationswillbecompletedbyaSelectedGeneralDentistwithqualificationsinthesameareaofexpertiseas thereferringSelectedGeneralDentistorSelectedGeneralDentistwhoprovidedtheinitialexaminationordentalcareservices.

YoumayrequestasecondopinionorobtainacopyoftheseconddentalopinionpolicybycontactingAccessDentaleitherbycalling(844)561‐5600orsendingawrittenrequesttothefollowingaddress:

AccessDentalPlan

MemberServices

POBox659032

Sacramento,CA95865‐9032

EmergencyDentalCare

EmergencyDentalCaremeans treatment to resolveanEmergencyDentalCondition (seeDefinitions“EmergencyDentalCondition”.EmergencyDentalCareistreatmentandproceduresadministeredinaDentist's office, dental clinic, or other comparable facility, to evaluate and stabilize an EmergencyDentalCondition.

All Selected General Dental Offices provide treatment for EmergencyDental Conditions twenty‐four(24)hoursaday,seven(7)daysaweekandweencourageYoutoseekcarefromYourSelectedGeneralDentalOffice.However,iftreatmentforanEmergencyDentalConditionisrequired,YoumaygotoanyDental Provider, go to the closest emergency room, or call 911 for assistance, as necessary. Priorauthorizationisnotrequired.

ServicesfortreatmentofanEmergencyDentalConditionwillnotbecoverediftreatmentisprovidedbyanOut‐of‐NetworkDentist.IfyouseekEmergencyDentalCarefromanOut‐of‐NetworkDentist,theOut‐of‐NetworkDentistmayrequireyoutomakeimmediatefullpaymentforservicesormayallowyoutopayanyapplicableCopayments.Ifyouhavetopayanyportionofthebill,wewillreimburseyouforservices that meet the definition of Emergency Dental Condition Care minus any applicableCopayments.Ifyoupayabill,pleasesubmitacopyofthebilltousforabenefitsdetermination.

YourreimbursementfromusfortreatmentforanEmergencyDentalCondition,ifany,islimitedtotheextentthetreatmentYoureceiveddirectlyrelatestotheevaluationandstabilizationoftheEmergencyDentalCondition.AllreimbursementswillbeallocatedinaccordancewiththisGroupContract,subjectto any exclusions and limitations. Hospital charges and/or other charges for care received at anyhospitaloroutpatientcarefacilityarenotCoveredServices.

If You receive treatment for an Emergency Dental Condition from an Out‐of‐Network Dentist, themaximumreimbursementtoyoufromAccessDentalislimitedto$100.00,YouwillberequiredtopayallchargestotheOut‐of‐NetworkDentistandsubmitaclaimtousforabenefitsdetermination.

UrgentCare

UrgentCareservicesareservicesneededtopreventseriousdeteriorationofyourhealthresultingfroman unforeseen illness or injury for which treatment cannot be delayed. All Selected General DentalOfficesprovidetreatmentforUrgentCareservicestwenty‐four(24)hoursaday,seven(7)daysaweek.Weencourageyou toobtainUrgentCare fromyourSelectedGeneralDentist/Office. If yourSelectedGeneralDentistisunabletoseeyouwithintwenty‐four(24)hours,youmustimmediatelycontactourMemberServicesDepartmentat(844)561‐5600andwewillarrangealternativedentalcareforyou.

ServicesthatdonotmeetthedefinitionofUrgentCarewillnotbecoverediftreatmentisprovidedbyan Out‐of‐Network Dentist. If you seek Urgent Care from an Out‐of‐Network Dentist, the Out‐of‐NetworkDentistmayrequireyoutomakeimmediatefullpaymentforservicesormayallowyoutopayany applicable Copayments. If you have to pay any portion of the bill, we will reimburse you forservices thatmeet thedefinitionofUrgentCareminus any applicableCopayments. If youpay abill,pleasesubmitacopyofthebilltousforabenefitsdetermination.


If You receive treatment for Urgent Dental Care from an Out‐of‐Network Dentist, the maximumreimbursementtoyoufromAccessDentalislimitedto$100.00,YouwillberequiredtopayallchargestotheOut‐of‐NetworkDentistandsubmitaclaimtousforabenefitsdetermination.

OnceyouhavereceivedUrgentCare,youmustcontactyourSelectedGeneralDentist(ifyourSelectedGeneralDentistdidnotperformtheservice)forfollow‐upcare.Youwillreceiveallfollow‐upcarefromyourSelectedGeneralDentist.

SpecialNeeds

If anEnrolleebelievesheor shehas a SpecialHealthCareneed, theEnrollee should contactAccessDental’s Customer Service department at (844) 561‐5600 Access Dental will confirm that a SpecialHealthCareNeedexistsandwhatarrangementscanbemadetoassisttheEnrolleeinobtainingsuchBenefits.AccessDentalshallnotberesponsibleforthefailureofanyContractDentisttocomplywithanylaworregulationconcerningstructuralofficerequirementsthatapplytoaDentisttreatingpersonswithSpecialHealthCareNeeds.

AccessingCare

Access Dental has made every effort to ensure that Our offices and the offices and facilities of theContractedDentistsandContractedSpecialistsareaccessibleforpatientswithmobilityimpairments.Ifyouarenotabletolocateanaccessibleprovider,pleasecallUstoll‐freeat(844)561‐5600andWewillhelpyoufindanalternateprovider.

Peoplewith hearing impairmentsmay contact Us through Our TDD number at (844) 561‐5600 forassistance.

This Combined Evidence of Coverage and Disclosure Form/ Contract and other important planmaterialsareavailableinlargeprint,enlargedcomputerdiskformats,andaudiotapeforpeoplewithvision impairments. For alternative formats, or for direct help in reading this document and othermaterials,pleasecallUsat(844)561‐5600.

AccessDental complieswith the AmericanswithDisabilities Act of 1990 (ADA). This Act prohibitsdiscriminationbasedondisability.

FacilityAccessibility

Manydental facilities provideAccessDentalwith information about special features of their offices,including accessibility information for patients with mobility impairments. To obtain informationregardingdental facility accessibility, contactAccessDental’s Customer Servicedepartment at (844)561‐5600.

WhatifIneedtochangeContractDentists?

YoumaychangeyourassignedPrimaryCareDentist bydirectinga request to theCustomerServicedepartmentorbyvisitingOurwebsiteatwww.premierlife.com.InordertoensurethatyourPrimaryCareDentist isnotifiedandOureligibility listsarecorrect,achangeinPrimaryCareDentistmustberequestedbeforethe15thdayofthemonthtobeeffectiveonthefirstdayofthefollowingmonth.Wewill provide an Enrollee written notice of assignment to another Contract Dentist facility near theEnrollee’shome, if1)a selected facility is closed to furtherenrollment,2)a chosenContractDentistwithdrawsfromtheProgram,or3)anassignedfacilityrequestsforgoodcause,thattheEnrolleebere‐assignedtoanotherContractDentist.AllTreatmentinProgressmustbecompletedbeforeyouchangetoanotherContractDentist.Forexample,thiswouldinclude1)partialorfulldenturesforwhichfinalimpressionshavebeentaken,2)completionofrootcanalsinprogressand3)deliveryofcrownswhenteethhavebeenprepared.


IfyourassignedPrimaryCareDentist terminatesparticipation inthisProgram,thatContractDentistwillcompleteallTreatmentinProgressasdescribedabove.

IfyourPrimaryCareDentistorotherdentalcareproviderstopsworkingwithAccessDental,Wewillletyouknowbymail60daysbeforethecontractterminationdate.

ContinuityofCare

Current Enrollees may have the right to the benefit of completion of care with their TerminatedProviderforcertainspecifieddentalconditions.PleasecallAccessDentalat(844)561‐5600toseeifyoumay be eligible for this benefit. Youmay request a copy of Access Dental’s Continuity of CarePolicy.YoumustmakeaspecificrequesttocontinueunderthecareofyourTerminatedProvider.WearenotrequiredtocontinueyourcarewiththatproviderifyouarenoteligibleunderOurpolicyorifwe cannot reach agreement with your Terminated Provider on the terms regarding your care inaccordancewithCalifornialaw.

Benefits,LimitationsandExclusions

ThisProgramprovidestheBenefitsdescribedintheScheduleofBenefitssubjecttothelimitationsandexclusionsalsodescribedinScheduleofBenefits.BenefitsareonlyavailableinthestateofCalifornia.TheservicesareperformedasdeemedappropriatebyyourattendingPrimaryCareDentist.

CopaymentsandOtherCharges

You are required to pay any Copayments listed in the Schedule of Benefits. Copayments are paiddirectlytotheDentistwhoprovidestreatment.

IntheeventthatwefailtopayaContractDentistorContractSpecialist,youwillnotbeliabletothatDentistforanysumsowedbyus.Bystatute,everycontractbetweenAccessDentalandourContractDentists and Contract Specialists contain a provision prohibiting a Contract Dentist or ContractSpecialistfromcharginganEnrolleeforanysumsowedbyAccessDental.

IfyouhavenotreceivedPreauthorizationfortreatmentfromaNon‐ParticipatingProvider,andwefailtopaythatNon‐ParticipatingProvider,youmaybeliabletothatNon‐ParticipatingProviderforthecostofservices.ForfurtherclarificationseeEmergencyServicesandSpecialistServices.

ObtainingaSecondOpinion

SometimesyoumayhavequestionsaboutyourconditionoryourPrimaryCareDentist’srecommendedtreatmentplan.YoumaywanttogetaSecondOpinion.YoumayrequestaSecondOpinionforanyreason,includingthefollowing:

Youquestionthereasonablenessornecessityofarecommendedprocedure.

Youhavequestionsaboutadiagnosisoratreatmentplanforachronicconditionoraconditionthatcouldcauselossoflife,lossoflimb,lossofbodilyfunction,orsubstantialimpairment.

Yourprovider’sadviceisnotclear,oritiscomplexorconfusing.

Yourproviderisunabletodiagnosetheconditionorthediagnosisisindoubtduetoconflictingtestresults.

Thetreatmentplaninprogresshasnotimprovedyourdentalconditionwithinanappropriateperiodoftime.


Youhaveattemptedtofollowthetreatmentplanorconsultedwithyourinitialproviderregardingyourconcernsaboutthediagnosisorthetreatmentplan.

YouoryourPrimaryCareDentistorContractedSpecialistmayrequestaSecondOpinionforCoveredServices.AfteryouoryourPrimaryCareDentisthasrequestedpermissiontoobtainaSecondOpinion,Wewillauthorizeordenyyourrequest inanexpeditiousmanner. Ifyourdentalconditionposesanimminentandseriousthreattoyourhealth,includingbutnotlimitedto,thepotentiallossoflife,limb,orothermajorbodily functionor ifadelaywouldbedetrimental toyourabilitytoregainmaximumfunction,yourrequestforaSecondOpinionwillbeprocessedwithin72hoursafterthePlanreceivesyourrequest.

AccessDentalmayalso request thatanEnrolleeobtaina secondopinion toverify thenecessityandappropriatenessofdentaltreatmentortheapplicationofBenefits.

IfyourrequesttoobtainaSecondOpinionisauthorized,youmustreceiveservicesfromaContractedDentist. If thereisnoqualifiedproviderinOurnetwork,WewillauthorizeaSecondOpinionfromaNon‐ParticipatingProvider.YouwillberesponsibleforpayinganyapplicableCopaymentsforaSecondOpinion.

IfyourrequesttoobtainaSecondOpinionisdeniedandyouwouldliketoappealOurdecision,pleaserefertotheGrievanceandAppealsProcessinthisbooklet.

ThisisasummaryofOurSecondOpinionpolicy.ToobtainacopyofOurpolicy,pleasecontactUsat(844)561‐8800.

ClaimsforReimbursement

ClaimsforcoveredEmergencyDentalServicesorpreauthorizedSpecialistServicesshouldbesenttouswithin90daysoftheendoftreatment.Validclaimsreceivedafterthe90‐dayperiodwillbereviewedifyoucanshowthatitwasnotreasonablypossibletosubmittheclaimwithinthattime.TheaddressforclaimssubmissionisAccessDental,P.O.Box659005,Sacramento,CA95865‐9005.

ProcessingPolicies

ThedentalcareguidelinesfortheAccessDentalProgramexplaintoContractDentistswhatservicesarecoveredunderthedentalContract.ContractDentistswillusetheirprofessionaljudgmenttodeterminewhichservicesareappropriatefortheEnrollee. ServicesperformedbytheContractDentistthatfallunder the scope of Benefits of the dental Program are provided subject to any Copayments. If aContractDentistbelievesthatanenrolleeshouldseektreatmentfromaspecialist,theContractDentistcontactsAccessDental for a determinationofwhether theproposed treatment is a covered benefit.AccessDentalwillalsodeterminewhethertheproposedtreatmentrequirestreatmentbyaspecialist.An Enrollee may contact Access Dental’s Customer Service department at (844) 561‐5600 forinformationregardingthedentalcareguidelinesforAccessDental.Intheeventthispolicyisissuedforachildunder19enrolledthroughCoveredCalifornia,thispolicywillserveasasecondpayor.AllclaimsmustgothroughthemedicalcarrierincludingpediatricdentalcoveragefirstandthenshallbesubmittedeitherbythemedicalplanorthemembertoAccessDental.

EnrolleeComplaintProcedure

Forgrievancesinvolvingthedelay,denial,ormodificationofdentalservices,OurresponsewilldescribethecriteriausedbyUsandtheclinicalreasonsforOurdecision,includingallthecriteriaandreasonsrelated todentalnecessity. In theevent thatwe issueadecisiondelaying,denyingormodifying thedental services based inwhole or in part on a finding that theproposed services arenot a coveredbenefitunderthiscontract,wewillclearlyspecifythedecisionandtheprovisionsinthiscontractthatexcludethecoverage.


If you have any complaint regarding eligibility, the denial of dental services or claims, the policies,proceduresoroperationsofAccessDental,or thequalityofdentalservicesperformedbyaContractDentistorContractSpecialist,youmaycallAccessDental’sCustomerServicedepartmentat(844)561‐5600,submitacomplaintonlinethroughOurwebsiteatwww.premierlife.com,orthecomplaintmaybeaddressedinwritingto:AccessDentalPlan,Inc.P.O.Box255039Sacramento,CA95865Written communication must include 1) the name of the patient, 2) the name, address, telephonenumber and identification number of the primary Enrollee, and 3) the Dentist’s name and facilitylocation.Within5calendardaysofthereceiptofanycomplaint,aQualityManagementcoordinatorwillforwardtoyouanacknowledgementofreceiptofthecomplaint. Certaincomplaintsmayrequirethatyoubereferredtoaregionaldentalconsultantforclinicalevaluationofthedentalservicesprovided.AccessDentalwillforwardtoyouadeterminationinwritingwithin30daysofreceiptofacomplaint. Ifthecomplaintinvolvesseverepainand/orimminentandseriousthreattoapatient’sdentalhealth,AccessDentalwillprovidetheEnrolleewrittennotificationregardingthedispositionorpendingstatusofthecomplaintwithinthreedays.IfyouhavecompletedAccessDental’sgrievanceprocess,oryouhavebeeninvolvedinAccessDental’sgrievanceprocedureformorethan30days,youmayfileacomplaintwiththeCaliforniaDepartmentofManagedHealthCare. Youmay file a complaintwith theDepartment immediately inanemergencysituation,whichisoneinvolvingseverepainand/orimminentandseriousthreattoyourhealth.The CaliforniaDepartment ofManagedHealth Care is responsible for regulating health care serviceplans.Ifyouhaveagrievanceagainstyourhealthplan,youshouldfirsttelephoneyourhealthplanat(844) 561‐5600 and use your health plan’s grievance process before contacting the Department.Utilizingthisgrievanceproceduredoesnotprohibitanypotentiallegalrightsorremediesthatmaybeavailable toyou. Ifyouneedhelpwithagrievance involvinganemergency,agrievance thathasnotbeensatisfactorilyresolvedbyyourhealthplan,oragrievancethathasremainedunresolvedformorethan30days,youmaycalltheDepartmentforassistance.YoumayalsobeeligibleforanIndependentMedicalReview(IMR).IfyouareeligibleforIMR,theIMRprocesswillprovideanimpartialreviewofmedical decisionsmade by a health plan related to themedical necessity of a proposed service ortreatment, coverage decisions for treatment that are experimental or investigational in nature andpayment disputes for emergency or urgent medical services. The Department also has a toll‐freetelephone number (1‐888‐HMO‐2219) and a TDD line (1‐877‐688‐9891) for the hearing andspeech impaired. The Department’s InternetWeb sitehttp://www.hmohelp.ca.gov has complaintforms,IMRapplicationformsandinstructionsonline.IMRisgenerallynotapplicabletoadentalplan,unlessthatdentalplancoversservicesrelatedtothepracticeofmedicineorofferedpursuanttoacontractwithahealthplanprovidingmedical,surgicalorhospitalservices.

EntireContract

This Combined Evidence of Coverage and Disclosure Form/ Contract, and any attached schedules,appendices, endorsements and riders, constitute the entire agreement governing the Program. Noamendment is valid unless approved by an executive officer of Access Dental and attached to thisbooklet.NoagentorbrokerhasauthoritytoamendthisContractorwaiveanyofitsprovisions.

PublicPolicyParticipationbyEnrollees

Access Dental’s Public Policy Committee includes Enrollees who participate in establishing AccessDental’s public policy regarding Enrollees through periodic review of Access Dental’s Quality


Management program reports and communications from Enrollees. Enrollees may submit anysuggestionsregardingAccessDental’spublicpolicyinwritingto:

AccessDentalPlan,Inc.P.O.Box659005Sacramento,CA95865‐9005

GoverningLaw

Any provision required to be included in this Disclosure Form/ Contract by California law andregulationbindsthePlanwhetherornotstated.

Access Dental shall comply in all respects with all applicable federal, state, and local laws andregulations relating to administrative simplification, security, andprivacy of individually identifiableenrollee information. Bothpartiesagree that thisContractmaybeamendedasnecessary tocomplywithfederalregulationsissuedundertheHealthInsurancePortabilityandAccountabilityActof1996or to comply with any other enacted administrative simplification, security or privacy laws orregulations.

CoordinationofBenefits

Coordination of Benefits (COB) is a process, regulated by law, which determines the financialresponsibility for paymentwhen aMember has coverage undermore than one plan. The primarycarrierpaysuptoitsmaximumliabilityandthesecondarycarrierconsiderstheremainingbalanceforcoveredservicesupto,butnotexceeding,thebenefitsthatareavailableandthedentist’sactualcharge.Determinationofprimarycoverageisasfollows:ForaGroupMedicalInsuranceQualifiedHealthPlan:AGroupMedicalInsuranceQualifiedHealthplanproviding pediatric dental essential health benefits is the primary carrier for such covered services.This applies to plans provided on the California Health Benefit Marketplace and to plans providedoutsidesuchMarketplace.For Dependent Children covered under Group Dental Plans: The determination of primary andsecondarycoverage forDependentchildrencoveredby twoparents’plans follows thebirthdayrule.Theplanof theparentwith theearlierbirthday (monthandday,notyear) is theprimarycoverage.Different rules apply for the children of divorced or legally separated parents; contact theMemberServicesDepartmentifyouhaveanyquestions.CoverageunderAccessDentalandanotherpre‐paiddentalplan:WhenanAccessDentalMemberhascoverageunderanotherprepaiddentalplan,whetherAccessDental is theprimaryor thesecondarycoverage,PCDmaynotcollectmorethantheapplicablePatientChargefromtheMember.CoverageunderAccessDentalandatraditionalorPPOfee‐for‐servicedentalplan:WhenaMemberiscoveredbyAccessDentalandafee‐for‐serviceplan,thefollowingruleswillapply:WhenAccessDentalisprimary,AccessDentalwillpaythemaximumamountrequiredbyitscontractorpolicywiththeMemberwhencoordinatingbenefitswithasecondarydentalbenefitplan.WhenAccessDentalissecondary,AccessdentalwillpaythelesserofeithertheamountthatwewouldhavepaidintheabsenceofanyotherdentalbenefitcoverageortheMember’stotalout‐of‐pocketcostpayableundertheprimarydentalbenefitplanforbenefitscoveredunderthesecondarydentalbenefitplan.AccessDentalwillnotcoordinatenorpayforthefollowing:Anyconditionforwhichbenefitsofanynaturearepaid,whetherbyadjudicationorsettlement,underanyWorkers’CompensationorOccupationalDiseaselaw.


Treatmentprovidedbyanypublicprogram,exceptMedicaid,orpaidfororsponsoredbyanygovernmentbody,unlesswearelegallyrequiredtoprovidebenefits.

GeneralProvisions

NoticeandProofofClaim

Writtennoticeof any claimmustbegiven toAccessDentalwithin180daysafter theoccurrenceorcommencementofanycoveredloss,orassoonthereafterasreasonablypossible.NoticemaybegiventoAccessDental,P.O.Box659005,Sacramento,CA95865‐9005.

Youmaycomplywithnoticerequirements for furnishingproofof lossbygivingwrittenproof. Suchwrittenproofmustcovertheoccurrence,thecharacterandtheextentoftheloss.AccessDentaldoesnotrequireclaimforms.

EligibilityofMedicaidNotConsidered

AccessDental shall not consider the availability or eligibility formedical assistanceunderMedicaid,when considering eligibility for coverage or making payments under this Combined Evidence ofCoverageandDisclosureForm/Contract.

Incontestability

AllstatementsmadeonyourEnrollmentFormshallbeconsideredrepresentationsandnotwarranties.Thestatementsareconsideredtobetruthfulandaremadetothebestofyourknowledgeandbelief.Astatementmaynotbeusedtovoid,cancel,ornon‐renewyourcoverageorreducebenefitsunless:1)itisinawrittenenrollmentapplicationsignedbyyou;and2)asignedcopyoftheenrollmentapplicationisorhasbeenfurnishedtoyouoryourrepresentative.Thiscontractmayonlybecontestedforfraudorintentionalmisrepresentationofmaterialfactmadeontheenrollmentapplication.

ThestatementsandinformationcontainedintheEnrollee’sEnrollmentFormarerepresentedbytheEnrolleetobetrueandcorrectandincorporatedintothisContract.TheEnrolleealsorecognizesthatAccessDentalhasissuedthiscontractinrelianceonthosestatementsandinformation.ThisContractreplacesandcancelsallothercontracts,ifany,issuedtotheEnrollee.

ConfidentialityofDentalRecords

ASTATEMENTDESCRIBINGACCESSDENTAL’SPOLICIESANDPROCEDURESREGARDINGTHECONFIDENTIALITYOFDENTALRECORDSISINCLUDEDINTHISCOMBINEDEVIDENCEOFCOVERAGEANDDISCLOSUREFORM/CONTRACTUNDERTHE“PRIVACYPRACTICES”SECTION.

OrganandTissueDonation

Donatingorgansandtissueprovidesmanysocietalbenefits.Organtissuedonationallowsrecipientsoftransplantstogoontoleadfullerandmoremeaningfullives.Currentlytheneedfororgantransplantsfar exceeds availability. If you are interested in organ donation, please speakwith your physician.Organdonationbeginsat thehospitalwhenamember ispronouncedbraindeadand identifiedasapotentialorgandonor.Anorganprocurementgroupwillbecomeinvolvedtocoordinatetheactivities.

PrivacyPractices

Except aspermittedby law,Enrollee information isnot releasedwithout youror your authorizedrepresentative’s consent. Enrollee‐identifiable information is shared onlywith Our consent or asotherwisepermittedby law. ThePlanmaintainspoliciesregarding theconfidentialityofEnrollee‐identifiableinformation,includingpoliciesrelatedtoaccesstodentalrecords,protectionofpersonalhealthinformationinallsettings,andtheuseofdataforqualitymeasurement.Wemaycollect,use,


andsharemedicalinformationwhenDentallyNecessaryorforotherpurposesaspermittedbylaw(suchasforqualityreviewandmeasurementandresearch.)

All of the Plan’s employees and providers are required tomaintain the confidentiality of Enrolleeinformation.Thisobligationisaddressedinpolicies,procedures,andconfidentialityagreements.AllproviderswithwhomWecontractaresubjecttoOurconfidentialityrequirements.

Inaccordancewithapplicablelaw,youhavetherighttoreviewyourownmedicalinformationandyouhavetherighttoauthorizethereleaseofthisinformationtoothers.

A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES FOR PRESERVING THECONFIDENTIALITYOFMEDICALRECORDSISPROVIDEDASATTACHMENT

IMPORTANT:CANYOUREADTHISDOCUMENT?IFNOT,WECANHAVESOMEBODYHELPYOUREADITFORFREEHELP,PLEASECALLACCESSDENTALAT(844)561‐5600.YOUMAYALSOBEABLETORECEIVETHISDOCUMENTINSPANISHORCHINESE.


EFFECTIVEDATESOFCOVERAGEThedateofAccessDentalcoveragebecomeseffectiveisbasedonwhenwereceiveyourapplicationandpayment.Ifyouhavequestionsafterreviewingthefollowing,pleasecontactusat(844)561‐5600.

MonthlyBankDraft:Ifyourpaymentarereceivedbythe25th]ofthemonth,youwillbeabletouseyourbenefitsonthefirstdayofthefollowingmonth.(e.g.,receivedbyMarch25,yourbenefitswillbeeffectiveApril1.Afterthe25thofMarch,yourbenefitswillbeeffectiveMay1.)MonthlyCreditCardDraft:Ifyourapplicationandpaymentisreceivedbythe25th,youwillbeabletouseyourbenefitsonthefirstdayofthefollowingmonth.(e.g.,receivedbyMarch25,yourbenefitswillbeeffectiveApril1.Afterthe25thofMarch,yourbenefitswillbeeffectiveMay1.)

ManagedcarebenefitsareprovidedbyAccessDentalPlan,Inc.


ATTACHMENTA–NoticeofPrivacyPractices

NOTICEOFPRIVACYPRACTICESEFFECTIVEAPRIL14,2003

THISNOTICEDESCRIBESHOWPROTECTEDHEALTHINFORMATIONABOUTYOUMAYBEUSEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION.PLEASEREVIEWITCAREFULLY.

ThisNoticetellsyouaboutthewaysAccessDentalPlan,Inc.(“AccessDental")maycollect,store,useanddiscloseyourprotectedhealthinformationandyourrightsconcerningyourprotectedhealthinformation.“ProtectedHealthInformation”isinformationaboutyouthatcanreasonablybeusedtoidentifyyouandthatrelatestoyourpast,presentorfuturephysicalormentalhealthorcondition,theprovisionofhealthcaretoyouorthepaymentforthatcare.

FederalandstatelawsrequireustoprovideyouwiththisNoticeaboutyourrightsandourlegaldutiesandprivacypracticeswithrespecttoyourprotectedhealthinformation.WemustfollowthetermsofthisNoticewhileitisstillineffect.SomeoftheusesanddisclosuresdescribedinthisNoticemaybelimitedincertaincasesbyapplicablestatelawsthataremorestringentthanthefederalstandards.

UsesandDisclosuresofYourProtectedHealthInformation

Wemayuseanddiscloseyourprotectedhealthinformationfordifferentpurposes.Theexamplesbelowareillustrationsofthedifferenttypesofusesanddisclosuresthatwemaymakewithoutobtainingyourauthorization.

Payment.Wemayuseanddiscloseyourprotectedhealthinformationinordertopayforyourcoveredhealthexpenses.Forexample,wemayuseyourprotectedhealthinformationtoprocessclaimsorbereimbursedbyanotherinsurerthatmayberesponsibleforpayment.

Treatment.Wemayuseanddiscloseyourprotectedhealthinformationtoassistyourhealthcareproviders(dentists)inyourdiagnosisandtreatment.

Health CareOperations. Wemay use and disclose your protected health information in order to perform our planactivities,suchasqualityassessmentactivities,oradministrativeactivities,includingdatamanagementorcustomerservice.Insomecases,wemayuseordisclosetheinformationforunderwritingordeterminingpremiums.

EnrolledChildren.Wewillmailexplanationofbenefitsformsandothermailingscontainingprotectedhealthinformationtotheaddresswehaveonrecordforthesubscriberofthedentalplan.

OtherPermittedorRequiredDisclosures

AsRequiredbyLaw.Wemustdiscloseprotectedhealthinformationaboutyouwhenrequiredtodosobylaw.

PublicHealthActivities.Wemaydiscloseyourprotectedhealthinformationtopublichealthagenciesforreasonssuchaspreventingorcontrollingdisease,injuryordisability.

VictimsofAbuse,NeglectorDomesticViolence. Wemaydisclose your protected health information to governmentagenciesaboutabuse,neglectordomesticviolence.

HealthOversightActivities. Wemaydiscloseprotectedhealthinformationtogovernmentoversightagencies(e.g.stateinsurancedepartments)foractivitiesauthorizedbylaw.

Judicial and Administrative Proceedings. We may disclose protected health information in response to a court oradministrative order. We may also disclose protected health information about you in certain cases in response to asubpoena,discoveryrequestorotherlawfulprocess.

Law Enforcement. We may disclose protected health information under limited circumstances to a law enforcementofficialinresponsetoawarrantorsimilarprocess;toidentifyorlocateasuspect;ortoprovideinformationaboutthevictimofacrime.

Coroners or Funeral Directors. We may release protected health information to coroners or funeral directors asnecessarytoallowthemtocarryouttheirduties.

Research. Undercertaincircumstances,wemaydiscloseprotectedhealth informationaboutyouforresearchpurposes,providedcertainmeasureshavebeentakentoprotectyourprivacy.


ToAvertaSeriousThreat toHealthorSafety. Wemaydiscloseprotectedhealth information about you,with somelimitations,whennecessarytopreventaseriousthreattoyourhealthandsafetyorthehealthandsafetyofthepublicoranotherperson.

SpecialGovernmentFunctions.Wemaydiscloseinformationasrequiredbymilitaryauthoritiesortoauthorizedfederalofficialsfornationalsecurityandintelligenceactivities.

Workers’Compensation.Wemaydiscloseprotectedhealthinformationtotheextentnecessarytocomplywithstatelawforworkers’compensationprograms.

OtherUsesorDisclosureswithanAuthorization

Otherusesordisclosuresofyourprotectedhealthinformationwillbemadeonlywithyourwrittenauthorization,unlessotherwisepermittedorrequiredbylaw.Youmayrevokeanauthorizationatanytimeinwriting,excepttotheextentthatwehavealreadytakenactionontheinformationdisclosedorifwearepermittedbylawtousetheinformationtocontestaclaimorcoverageunderthePlan.

YourRightsRegardingYourProtectedHealthInformation

YoumayhavecertainrightsregardingprotectedhealthinformationthatthePlanmaintainsaboutyou.

RighttoAccessYourProtectedHealthInformation.Youhavetherighttorevieworobtaincopiesofyourprotectedhealthinformationrecords,withsomelimitedexceptions.Usuallytherecordsincludeenrollment,billing,claimspaymentandcaseormedicalmanagementrecords.Yourrequesttoreviewand/orobtainacopyofyourprotectedhealthinformationmustbemadeinwriting.Wemaychargeafeeforthecostsofproducing,copyingandmailingyourrequestedinformation,butwewilltellyouthecostinadvance.

Right toAmendYourProtectedHealth Information. If you feel thatyourprotectedhealth informationmaintainedbyAccessDental is incorrector incomplete,youmayrequestthatweamendthe information. Yourrequestmustbemadeinwritingandmustincludethereasonyouareseekingachange.Wemaydenyyourrequest,ifforexample,youaskustoamendinformationthatwasnotcreatedbyAccessDentaloryouaskustoamendarecordthatisalreadyaccurateandcomplete.Ifwedenyyourrequesttoamend,wewillnotifyyouinwriting.Youthenhavetherighttosubmittousawrittenstatementofdisagreementwithourdecisionandwehavetherighttorebutthatstatement.

Right toanAccountingofDisclosures. Youhave the right request an accountingofdisclosureswehavemadeof yourprotectedhealthinformation.Thelistwillnotincludeourdisclosuresrelatedtoyourtreatment,ourpaymentorhealthcareoperations,ordisclosuresmadetoyouorwithyourauthorization.Thelistmayalsoexcludecertainotherdisclosures,suchasfornationalsecuritypurposes. Yourrequestforanaccountingofdisclosuresmustbemadeinwritingandmuststateatimeperiodforwhichyouwantanaccounting.ThistimeperiodmaynotbelongerthansixyearsandmaynotincludedatesbeforeApril14,2003.Yourrequestshouldindicateinwhatformyouwantthelist(paperorelectronically).Foradditionallistswithinthesametimeperiod,wemaychargeforprovidingtheaccounting,butwewilltellyouthecostinadvance.

RighttoRequestRestrictionsontheUseandDisclosureofYourProtectedHealthInformation.Youhavetherighttorequestthatwerestrictorlimithowweuseordiscloseyourprotectedhealthinformationfortreatment,paymentorhealthcare operations. Wemay not agree to your request. If we do agree, we will comply with your request unless theinformationisneededforanemergency.Yourrequestforarestrictionmustbemadeinwriting.Inyourrequest,youmusttellus(1)what informationyouwantto limit;(2)whetheryouwantto limithowweuseordiscloseyour information,orboth;and(3)towhomyouwanttherestrictionstoapply.

Right to Receive Confidential Communications. You have the right to request that we use a certain method tocommunicatewithyouor thatwesend information toa certain location if thecommunication couldendangeryou. Yourrequesttoreceiveconfidentialcommunicationsmustbemadeinwriting.Yourrequestmustclearlystatethatallorpartofthecommunicationfromuscouldendangeryou.Wewillaccommodateallreasonablerequests.Yourrequestmustspecifyhoworwhereyouwishtobecontacted.

RighttoaPaperCopyofThisNotice.YouhavearightatanytimetorequestapapercopyofthisNotice,evenifyouhadpreviouslyagreedtoreceiveanelectroniccopy.

ContactInformationforExercisingYourRights. YoumayexerciseanyoftherightsdescribedabovebycontactingourPrivacyOfficer.SeetheendofthisNoticeforthecontactinformation.


HealthInformationSecurityAccessDentalrequiresitsemployeestofollowitssecuritypoliciesandproceduresthatlimitaccesstohealthinformationaboutmemberstothoseemployeeswhoneedittoperformtheirjobresponsibilities. Inaddition,AccessDentalmaintainsphysical,administrativeandtechnicalsecuritymeasurestosafeguardyourprotectedhealthinformation.

ChangestoThisNoticeWereservetherighttochangethetermsofthisNoticeatanytime,effectiveforprotectedhealthinformationthatwealreadyhaveaboutyouaswellasanyotherinformationthatwereceiveinthefuture.WewillprovideyouwithacopyofthenewNoticewheneverwemakeamaterialchangetotheprivacypracticesdescribedinthisNotice.AnytimewemakeamaterialchangetothisNotice,wewillpromptlyreviseandissuethenewNoticewiththeneweffectivedate.

ComplaintsIfyouareconcernedthatwehaveviolatedyourprivacyrights,oryoudisagreewithadecisionwemadeaboutaccesstoyourrecords,youmayfileacomplaintwithusbycontactingthepersonlistedbelow.YoumayalsosendawrittencomplainttotheU.S.DepartmentofHealthandHumanServices. Thepersonlistedbelowcanprovideyouwiththeappropriateaddressuponrequest.Wesupportyourrighttoprotecttheprivacyofyourprotectedhealthinformation.Wewillnotretaliateagainstyouorpenalizeyouforfilingacomplaint.

OurLegalDutyWearerequiredbylawtoprotecttheprivacyofyourinformation,providethisnoticeaboutourinformationpractices,andfollowtheinformationpracticesthataredescribedinthisnotice.Ifyouhaveanyquestionsorcomplaints,pleasecontact:

PrivacyOfficer Phone:(916)920‐2500AccessDentalPlan,Inc. Fax: (916)646‐9000P.O.Box:659010 Email:[email protected],CA95865‐9010


ATTACHMENTB–AuthorizationtoUse&DiscloseHealthInformation

AUTHORIZATIONTOUSE&DISCLOSEHEALTHINFORMATIONNameofMember:____________________________________________I.D.Number:_______________________________AddressofMember:____________________________________________________________________________________IauthorizeAccessDentalPlan,Inc.touseanddiscloseacopyofthespecifichealthanddentalinformationdescribedbelow.Informationconsistingof:(Checkallthatapply.)

Eligibility Benefits Claims PriorAuthorizations/SpecialtyReferrals

Other(Pleasespecify)__________________________________________________________________________NameofthePerson(s)orOrganization(s)towhomyouauthorizeustouseordiscloseyourinformation:

Pleasecheckallthatapply,andlistthenameororganization:

Spouse_______________________________________ Mother_____________________________________

Employer____________________________________ Father_____________________________________

Child_________________________________________ Other______________________________________Forthepurposeof:(Describeintendeduseorpurposeofthisdisclosure)________________________________________________________________________________________________________________________________________________________________________________________________________ExpirationofAuthorization:(ForhowlongdoyouwishthisAuthorizationtolast)

1year 3years 5years Noexpiration Other______________________________________IfwearerequestingthisAuthorizationfromyouforourownuseanddisclosureortoallowanotherhealthcareproviderorhealthplantodiscloseinformationtous: Wecannotconditionourprovisionofservicesortreatmenttoyouonthereceiptofthissignedauthorization; Youmayinspectacopyoftheprotectedhealthinformationtobeusedordisclosed; YoumayrefusetosignthisAuthorization;and Wemustprovideyouwithacopyofthesignedauthorization.

YouhavetherighttorevokethisAuthorizationatanytime,providedthatyoudosoinwritingandexcepttotheextentthatwehavealreadyusedordisclosedtheinformationinrelianceonthisAuthorization.

Unlessrevokedearlierorotherwiseindicated,thisAuthorizationwillexpireoneyearfromthedateofsigningorshallremainineffectfortheperiodreasonablyneededtocompletetherequest.

IhavereviewedandIunderstandthisAuthorization.IalsounderstandthattheinformationusedordisclosedpursuanttothisAuthorizationmaybesubjecttore‐disclosurebytherecipientandnolongerbeprotectedunderfederallaw.By:___________________________________________________________Date:__________________________SignatureofMember(orauthorizedrepresentative,ifMemberisaminor)


PrintedNameofAuthorizedRepresentative_______________________________________________________RelationshiptoMember_______________________________________________________________________PleasemailthisformtoAccessDental,Attn:CustomerService,P.O.Box659010,Sacramento,CA95865‐9010.YoumayalsoFAXtheformto1[(916)646‐9000]totheAttentionofCustomerService.

IMPORTANT NOTICE REGARDING LANGUAGE ASSISTANCE & DISCRIMINATION AVISO IMPORTANTE SOBRE LA ASISTENCIA DE IDIOMA Y DISCRIMINACIÓN

GC017586 Critical Docs 9/13/16 Port

English

If you or the person you are helping has questions about your insurance benefits, claims, or coverage, you have the right to get help and information in your language at no cost. To talk to an interpreter: if you have insurance from your employer, call the telephone number on your identification card; for all other members, please call 844-561-5600. The Guardian and its subsidiaries* comply with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Spanish Español

Si usted o la persona que está ayudando tiene preguntas acerca de su seguro, las reclamaciones o cobertura, usted tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete: si tiene seguro de su empleador, llame al número de teléfono que aparece en su tarjeta de identificación; para todos los demás miembros, por favor llame al 844-561-5600. The Guardian y sus subsidiarias * cumplir con las leyes federales aplicables de derechos civiles y no discrimina por motivos de raza, color, origen nacional, edad, discapacidad, o sexo.

Chinese

中文

如果你或你正在帮助的人拥有约你的保险利益，索赔或覆盖的问题，你有没有成本，以获取帮助和信息在你的语言的权利。要交谈

的解释：如果您从您的雇主有保险，打电话给你的身份证上的电话号码;所有其他成员，请致电 844-561-5600。

卫报及其子公司*遵守适用的联邦民权法和种族，肤色，国籍，年龄，残疾，或性的基础上不歧视。

Vietnamese Tiếng Việt

Nếu bạn hoặc người bạn đang giúp đỡ có câu hỏi về quyền lợi bảo hiểm, yêu cầu của bạn, hoặc bảo hiểm, bạn có quyền được trợ giúp và thông tin trong ngôn ngữ của bạn miễn phí. Để nói chuyện với một thông dịch viên: nếu bạn có bảo hiểm từ công ty của bạn, hãy gọi số điện thoại trên thẻ nhận dạng của bạn; cho tất cả các thành viên khác, xin vui lòng gọi 844-561-5600. The Guardian và các công ty con của nó * tuân thủ pháp luật quyền dân sự liên bang áp dụng và không phân biệt đối xử trên cơ sở chủng tộc, màu da, nguồn gốc quốc gia, tuổi tác, khuyết tật, hoặc quan hệ tình dục.

Korean

한국어

당신이나 당신이 도움이되고 사람이 당신의 보험 혜택, 청구, 또는 범위에 대한 질문이있는 경우, 당신은 무료로 귀하의 언어로

도움과 정보를 얻을 수있는 권리가 있습니다. 통역 얘기하려면, 당신은 당신의 고용주로부터 보험이있는 경우, 귀하의 ID 카드에

전화 번호로 전화; 다른 모든 구성원에 대해, 844-561-5600로 전화 해주십시오.

가디언과 그 자회사는 해당 연방 민권법을 준수하고 인종, 피부색, 출신 국가, 연령, 장애, 또는 성별에 근거하여 차별하지 않습니다 *.

Tagalog Tagalog

Kung ikaw o ang taong ikaw ay pagtulong ay may mga katanungan tungkol sa inyong mga benepisyo sa insurance, claims, o coverage, ikaw ay may karapatan upang makakuha ng tulong at impormasyon sa iyong wika nang walang gastos. Upang makipag-usap sa isang interpreter: kung mayroon kang insurance mula sa iyong tagapag-empleyo, tawagan ang numero ng telepono sa iyong identification card; para sa lahat ng iba pang mga miyembro, mangyaring tumawag sa 844-561-5600. The Guardian at ang mga subsidiaries * sumusunod sa naaangkop na mga Pederal na batas sa mga karapatang sibil at hindi maaaring makita ang kaibhan sa batayan ng lahi, kulay, bansang pinagmulan, edad, kapansanan, o sex.

Russian Pусский

Если вы или человек, которому вы помогаете есть вопросы по поводу вашего страховых выплат, претензий, или покрытия, вы имеете право получить помощь и информацию на вашем языке без каких-либо затрат. Для того, чтобы поговорить с переводчиком: если у вас есть страхование от Вашего работодателя, позвоните по номеру телефона на вашей идентификационной карточки; для всех остальных членов, просьба звонить по телефону 844-561-5600. The Guardian и его дочерние компании * соответствии с действующими федеральными законами о гражданских правах и не допускать дискриминации по признаку расы, цвета кожи, национального происхождения, возраста, инвалидности или пола.

Arabic العربية

التحدث الى . في لغتك دون أي تكلفة إذا كنت أنت أو الشخص الذي يساعد ديه أسئلة حول فوائد التأمين والمطالبات، أو تغطية، لديك الحق في الحصول على المساعدة والمعلومات

.1655-165-844لجميع الأعضاء، يرجى الاتصال . الهاتف على بطاقة الهوية الخاصة بكإذا كان لديك التأمين من صاحب العمل الخاص بك، الاتصال على رقم : مترجم

..لجنسالالتزام بالقوانين الاتحادية المطبقة الحقوق المدنية ولا تميز على أساس العرق أو اللون أو الأصل القومي أو السن أو الإعاقة، أو ا* الجارديان والشركات التابعة لها

French Creole-Haitian Creole

Kreyòl Ayisyen

Si ou menm oswa moun nan w ap ede gen kesyon sou benefis asirans ou, reklamasyon, oswa pwoteksyon, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou a pa koute. Pou pale ak yon entèprèt: si ou gen asirans nan men anplwayè ou, rele nimewo telefòn sou kat idantifikasyon ou; pou tout lòt manm, tanpri rele 844-561-5600. The Guardian ak filiales li yo * konfòme yo avèk lwa sou dwa sivil Federal aplikab yo, epi pa fè diskriminasyon sou baz ras, koulè, orijin nasyonal, laj, andikap, oswa fè sèks.

Polish Polskie

Jeśli Ty lub osoba, do której pomoc ma pytania dotyczące świadczeń z ubezpieczenia, roszczenia lub pokrycia, masz prawo do uzyskania pomocy i informacji w swoim języku, bez żadnych kosztów. Aby rozmawiać z tłumacza: jeśli masz ubezpieczenie od pracodawcy, należy zadzwonić pod numer telefonu na karcie identyfikacyjnej; dla wszystkich pozostałych członków, zadzwoń 844-561-5600. The Guardian i jej spółek zależnych * przestrzegania obowiązujących przepisów federalnych praw obywatelskich i nie dyskryminacji ze względu na rasę, kolor skóry, pochodzenie narodowe, wiek, niepełnosprawność, czy płeć.

GC017586 Critical Docs 9/13/16 Port

French Français

Si vous ou la personne que vous aidez a des questions sur vos prestations d'assurance, les prétentions ou la couverture, vous avez le droit d'obtenir de l'aide et de l'information dans votre langue, sans frais. Pour parler à un interprète: si vous avez l'assurance de votre employeur, appelez le numéro de téléphone sur votre carte d'identité; pour tous les autres membres, s'il vous plaît appelez 844-561-5600. The Guardian et ses filiales * sont conformes aux lois fédérales relatives aux droits civils applicables et ne fait pas de discrimination sur la base de la race, la couleur, l'origine nationale, l'âge, le handicap ou le sexe.

Italian Italieno

Se voi o la persona che state aiutando ha domande circa la vostra prestazioni assicurative, reclami, o la copertura, si ha il diritto di richiedere assistenza e informazioni nella propria lingua, senza alcun costo. Per parlare con un interprete: se avete l'assicurazione dal datore di lavoro, chiamare il numero di telefono sulla carta d'identità; per tutti gli altri membri, si prega di chiamare 844-561-5600. The Guardian e le sue controllate * conformi alle leggi federali vigenti diritti civili e non discrimina sulla base di razza, colore, nazionalità, età, disabilità, o di sesso.

Persian-Farsi

سی ار سی-ف ار ف

و اطلاعات به زبان خود را بدون هيچ هزينه اگر شما يا شخصی که شما در حال کمک به سوالات در مورد مزايای بيمه خود را، ادعا می کند، و يا پوشش، شما حق دريافت کمک

تماس 1655-165-844برای همه اعضای ديگر، لطفا . اگر بيمه از کارفرمای خود، تماس با شماره تلفن بر روی کارت شناسايی خود را: برای صحبت با يک مترجم. داشته باشد

..بگيريد

.ل حقوق مدنی قابل اجرا می کند و بر اساس نژاد، رنگ پوست، مليت، سن، معلوليت و يا رابطه جنسی قائل نمی شودمطابق با قوانين فدرا* * * * گاردين و شرکتهای تابعه آن

Armenian

Hայերեն Եթե դուք կամ այն անձը, դուք օգնում ունի հարցեր ձեր ապահովագրական հատուցումներից, պահանջների, կամ

լուսաբանման, դուք իրավունք ունեք ստանալու օգնություն եւ տեղեկատվություն Ձեր լեզվով ոչ մի գնով: Խոսել է թարգմանչի:

Եթե ունեք ապահովագրություն Ձեր գործատուի, զանգահարեք հեռախոսահամարը Ձեր նույնականացման քարտ. բոլոր մյուս

անդամների համար, խնդրում ենք զանգահարել 844-561-5600.

The Guardian եւ իր դուստր ձեռնարկություններն * համապատասխանեն կիրառելի դաշնային քաղաքացիական իրավունքների

օրենքների եւ չի խտրականություն հիման վրա ռասայի, մաշկի գույնի, ազգային ծագման, տարիքի, հաշմանդամության, կամ

սեռից:

German Deutsche

Wenn Sie oder die Person, die Sie helfen, Fragen zu Ihrem Versicherungsleistungen , Ansprüche oder Abdeckung, haben Sie das Recht auf kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um auf einen Dolmetscher sprechen: Wenn Sie eine Versicherung von Ihrem Arbeitgeber haben, rufen Sie die Telefonnummer auf der Ausweiskarte ; für alle anderen Mitglieder, rufen Sie bitte 844-561-5600. The Guardian und ihre Tochtergesellschaften * mit den geltenden Bundes Bürgerrechte Gesetze einhalten und nicht zu diskriminieren auf der Grundlage von Rasse, Hautfarbe , nationaler Herkunft, Alter, Behinderung oder Geschlecht.

Portuguese Português

Se você ou a pessoa que você está ajudando tem dúvidas sobre seus benefícios de seguro, reivindicações, ou cobertura, você tem o direito de obter ajuda e informações na sua língua, sem nenhum custo. Para falar com um intérprete: se você tem seguro de seu empregador, ligue para o número de telefone no seu cartão de identificação; para todos os outros membros, ligue para 844-561-5600. Este aviso tem informações importantes sobre a sua aplicação ou sua cobertura de seguro. Olhe para as datas-chave neste The Guardian e suas subsidiárias * cumprir com as leis federais aplicáveis direitos civis e não discriminar com base em raça, cor, nacionalidade, idade, deficiência ou sexo.

*Guardian Life Insurance Company of America subsidiaries includes First Commonwealth Companies, Managed Dental Care, Inc., Managed Dental Guard, Inc., Premier

Access Insurance Company and Access Dental Plan, Inc.