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TABLE OF CONTENTS Section Page NOTICE FOR RESIDENTS OF CALIFORNIA .............. .................. .................................................................. 4 Confidentialityof Dental Records ....................................................................................... . ........ .................. 4 OrganDonation ..... ......................................................................................................................................... 4 LanguageAssistance .................................................... ................................................................................. 4 NOTICE FOR RESIDENTS OF ALL STATES ........ ......... ... ................................................... I ........................... 5 Notice Regarding Your Rights and Responsibilities.. ...................................................................................... 5 Rights................ .................... .................................. .................................................................................. 5 Responsibilities................................... ........................................................................................................ 5 DENTALBENEFITS ................................................................................................................ I ... ................. 6 Dentist -Patient Relationship ............................................................................................................................ 6 WhoMay Enroll ............................................................................................................................................... 6 SERVICEAREA............................................................... .................................... ................................. ........... 7 DEPENDENTCOVERAGE ......................................................... ... ........................................................ ........... 7 WHENCOVERAGE BEGINS ..................................................... I ...... I ................................................................ 7 Choiceof Dentists ............................................................................................................................................ 7 Facilities........................................................................................................................................................... 7 Changing Your Selected General Dental Office .............................................................................................. a ProviderReimbursement ......................................................................... ...................................................... 8 Liability of Subscriber or Enrollee for Payment ............. .................................................................................. 8 PrepaymentFee ....... ........................................................................ .......................................................... 8 Co -Payments ............................. ................................................................................................................. 8 Orthodontic Covered Services .............................. ............................................................................... ..... . 9 YearlyMaximums ........................................................................................................................ ................ 9 Covered Services After Dental Coverage Ends .......................................................... ................................ 9 Mon -Covered Services ........ ........................................................................................................................ 9 OtherCharges .............................................................................................................................................. 9 ReimbursementProvisions .............................................................................................................................. 9 SpecialtyCare Referrals ..................................................................... ............................................................ 9 SecondOpinion ........ .................................................................................................................................... 10 Emergency Dental Care ................................................................................................................................ 10 TERMINATION OF BENEFITS ................................ ................. 1. ..................................... ......... I_.. ... I ..... 11 Cancellationof Benefits ................................................................................................................................. 11 RenewalProvisions ....................................................................................................................................... 12 Reinstatement................................................................................................................................................ 12 Disenrallment................................................................................................................................................. 12 CONTINUITYOF CARE ............................................................... .................................. ................................ 12 CurrentMembers ..................................... ................................................. ........................... ....................... 12 NewMembers ................................................................................................................................................ 12 DENTAL BENEFITS: INQUIRIES AND GRIEVANCE PROCEDURES ............................................................13 Routine Questions About Dental Benefits ..................................................................................................... 13 GrievanceProcedures ................................................................................................................................... 13 Arbitration .......... 14 Coordination of ............. * .......................... ...................... ......... 14 Third Party Liability ........ ; .................................. ....................................... 14 Assignment of Banafits..i'� . ......... ............ 14 INDIVIDUAL CONTINUATION OF DENTAL BENEFITS WITH PAYMENT OF THE PREPAYMENT FEE..... 14 For Mentally Or Physically Handicapped Children ........................................................................................ 14 ForFamily And Medical Leave .................................................... ...................................... - ......................... 15 AtThe Organization's Option ........................................................................................................................ .15 COBRA CONTINUATION FOR DENTAL BENEFITS .................... I .................... ....................... I ................... . 15 Cal -Cobra Continuation For Dental Benefits ............................... ................................................................. 15 Events that Allow Continuation, and Length of Continuation ................................. ................................... 15 NowDependents ............................................................................... .......................... ............................. is Terminationof Coverage., .................................................. ....................................................................... 15 Noticeand Election of Coverage ................................................................................................................ 16 Costof Continued Coverage ..................................... .............. ................................................................. 17 Paymentof the Prepayment Fees ............................................................................ .................. .............. 17 Exceptions......... .................................................................................................... ................................... 17 OCERT2011-DHMO-EOC 250-16