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Benefits Provided by SafeGuard Health Plans, Ino„ a MetLife company
200 Park Avenue, New York, New York 10166
A-2018-020
SafaGuard Health Plans, Ino. ("SafeGuard"), a California corporation, will pay the benefits specified In the
Exhibits of this contract subject to the terms and provisions of this contract. The Schedule of Exhibits lists
each Exhibit to this contract, to whom it applies and its effective date.
Organization:
Group Contract No.:
EFFECTIVE DATE
City of Santa Ana
142337
This contract will take effect on January 1, 201 S.
CONTRACT ANNIVERSARIES
Contract anniversaries will be January 1, 2019 and each subsequent January 1.
PREPAYMENT FEES
This contract is issued in return for the payment of required Prepayment Fees. Prepayment Fees are
payable at the home offloe of SafeGuard or to Its authorized agent. The first Prepayment Fee Is due on
and must be pald by this contract's effective date. Any later Prepayment Fees are due monthly in
advance on the first day of each Contract Month. These dates are the Prepayment Fee Due gates.
SafeGuard and the Organization may agree that payment be made In advance every 3, 6 or 12 months.
CONTRACT SITUS
This contract Is Issued for delivery in and governed by the laws of California.
Signed as of this contract's effective date at SafeGuard's home office in Irvine, California.
Signature
SafeGuard Representative
GROUP SPECIALIZED HEALTH CARE SERVICE PLAN
GPNP10-DHMO
25C-3
Page 1
TABLE OF CONTENTS
Section
Page
POLICY FACE PAGE
EffectiveDate.............................................................................................................................................1
ContractAnniversaries...............................................................................................................................1
PrepaymentFees.......................................................................................................................................1
ContractSitus ............................................................................................................................................1
DEFINITIONS................................................................................................................................................ 3
SCHEDULEOF BENEFITS...........................................................................................................................3
ELIGIBILITY AND EFFECTIVE DATES OF BENEFITS................................................................................4
CONTRIBUTIONS..............................................................................................................................................
4
EntireContract...........................................................................................................................................7
PREPAYMENTFEES....................................................................................................................................4
Incontestability: Statements Made by the Organization............................................................................7
InitialPrepayment Fee...............................................................................................................................4
Frequency of Prepayment Fee Payment....................................................................................................4
Computation of the Prepayment Fee.........................................................................................................4
Prepayment Fee for Changes in Benefits..................................................................................................4
Rightto Change the Prepayment Fee........................................................................................................4
GRACEPERIOD...........................................................................................................................................5
END OF BENEFITS PROVIDED BY THIS CONTRACT...............................................................................6
REINSTATEMENT.............................................................................................................................................. 7
GENERAL PROVISIONS..............................................................................................................................7
EntireContract...........................................................................................................................................7
ContractChanges or Waivers....................................................................................................................7
Incontestability: Statements Made by the Organization............................................................................7
Incontestability: Statements Made by Covered Persons...........................................................................7
Evidenceof Coverage................................................................................................................................8
ParticipatingProviders...............................................................................................................................8
Assignment................................................................................................................................................8
DataNeeded..............................................................................................................................................8
Misstatementof Age...................................................................................................................................8
Non -Dividend Paying.................................................................................
.........,........... 8
Conformitywith Law...............................................................................................................................
. .8
SCHEDULE OF EXHIBITS SCH/EXHIBITS
EXHIBIT 1: Prepayment Fee Schedule.......................................................................EXHIBIT 1
EXHIBIT 2: Evidence of Coverage Form......................................................................EXHIBIT 2
EXHIBIT 3: Schedule of Benefits................................................................................EXHIBIT 3
GPNP10-DHMO
25C-4
Page 2
DEFINITIONS
As used in this contract, the terms listed below will have the meanings defined below. When defined
terms are used In this contract, they will appear with initial capitalization, The plural use of a term defined
In the singular will share the same meaning,
Contract Anniversary Is defined on page 1,
Contribution means the amount the Organization may require the Member to pay toward the total
Prepayment Fee that MetLife charges for the benefits provided by this contract.
Contributory Benefits means benefits for which the Organization may require the Member to pay at
least part of the Prepayment Fee.
Covered Person means a Member and/or a Dependent as set forth in the Exhibit which applies to the
Member.
Contract Month. The first Contract Month will begin on the effective date shown on page 1. Subsequent
Contract Months will begin on the same day of each subsequent calendar month.
Dependent is defined in the Exhibit which applies to the Member.
Member means the person, usually the employee, who represents the family unit in relation to the dental
benefits.
Noncontributory Benefits means benefits for which the Organization may not require the Member to pay
any part of the Prepayment Fee.
Policyholder means the Organization shown on page 1.
Prepayment Fee means the amount the Organization must pay to SafeGuard for all the benefits provided
under this contract.
Prepayment Fee Due Date Is defined on page 1.
Selected General Dentist means a SafeGuard contracted dentist who agrees in Writing to provide dental
services under special terms, conditions and financial reimbursement arrangements with SafeGuard.
Selected General Dental Office means a dental office contracted with SafeGuard consisting of dentists
who agree in Writing to provide dental services under special terms, conditions and financial reimbursement
arrangements with SafeGuard.
Signed means any symbol or method executed or adopted by a person with the present intention to
authenticate a record, and which is on or transmitted by paper or electronic media, and which Is consistent
with applicable law,
Written or Writing means a record which Is on or transmitted by paper or electronic media, and which is
consistent with applicable law.
SCHEDULE OF BENEFITS
The schedules of benefits which apply under this contract are set forth in the Exhibits.
GPNP10•DHM0
25C-5
Page 3
ELIGIBILITY AND EFFECTIVE DATES OF BENEFITS
The Eligibility and Effective Dates of Benefits provisions that apply under this contract are set forth in the
Exhibits.
CONTRIBUTIONS
The Organization will not require a Member to contribute to the cost of Noncontributory Benefits.
The maximum amount that a Member may be required to contribute to the cost of Contributory Benefits will
not exceed the Prepayment Fee charged for the amounts of such benefits.
PREPAYMENTFEES
Initial Prepayment Fee
The initial Prepayment Fee is shown In the Exhibits.
Frequency of Prepayment Fee Payment
Prepayment Fees for this contract will be paid as shown on page 1. SafeGuard and the Organization may
agree that payment be made In advance every 3, 6, or 12 months.
Computation of the Prepayment Fee
The Prepayment Fee due on any Prepayment Fee Due Date Is determined by the total amount of benefits
provided by this contract on such Prepayment Fee Due Date, multiplied by the appropriate Prepayment
Fee which is then In effect subject to any Prepayment Fee adjustments, 'rf applicable.
SafeGuard may use any reasonable method to compute Prepayment Fees due under this contract.
Prepayment Fee for Changes in Benefits
For benefits that take effect after the first day of a Contract Month, the Prepayment Fee will be charged
from the first day of the next Contract Month. However, if a contract amendment Is required for such
benefits, The Prepayment Fee will be charged as of the date such benefits take effect.
If this contract ends, or if benefits and for a class of persons, the Prepayment Fee will be charged to the
date benefits end. if benefits end for other reasons, the Prepayment Fee will be charged to the end of the
Contract Month in which benefits end,
Right to Change the Prepayment Fee
SafeGuard may change Prepayment Fees for changes which materially affect the risk assumed for the
benefits provided by this contract, as follows:
1. when this contract is amended or endorsed;
2, when a class of eligible persons is added to or deleted from this contract for any reason including
corporate restructuring, acquisition, spin-off or similar situations;
GPNPIO.OHMO
25C-6
Page b
Right to Change the Prepayment Fee (continued)
S. when the Organization's subsidiary, affiliate, division, branch or other similar entity Is added to or
deleted from this contract for any reason Including corporate restructuring, acquisition, spin-off or
similar situations;
4. when there is a significant change In the geographic distribution of Covered Persons;
S. when applicable law requires a change in:
a. the benefits provided by this contract; and/or
b. the class of persons eligible for benefits under this contract; or
5. when a Prepayment Fee Due Date coincides with or next follows:
a. a change greater than 10% In the number of Covered Persons since the later of the contract
Effective Date and the last date that the Prepayment Fee was changed; or
b, a change greater than 5% in the amount of benefits provided by this contract since the later of the
contract Effective Date and the last date that the Prepayment Fee was changed.
In addition, SafeGuard may change the Prepayment Fee:
1. except as maybe stated in the Exhibits, on any date on or after the first Contract Anniversary; this will
be done no more frequently than every 12 months and only if SafeGuard notifies the Organization, In
Writing, at least 30 days before such change; and
2, on any other date agreed to by SafeGuard and the Organizatlon.
The new Prepayment Fee will apply only io a Prepayment Fee due on or after the date the rate change
takes effect.
GRACE PERIOD
Each Prepayment Fee due after the Effective Date of this contract may be paid up to 15 days after its
Prepayment Fee Due Date, This period is the grace period. The benefits provided by this contract will
stay in effect during this period. SafeGuard will notify the Organization in Writing that, if the Prepayment
Fee Is not paid by the end of the grace period, this contract will end at the end of the last day of the grace
period. If SafeGuard falls to give Written notice to the Organization, this contract will continue in effect
until the date such notice is given.
Organization's intent to end this contract during the grace period. The Organization may notify
SafeGuard In Writing prior to the end of the grace period of its intent to end this contract before the end of
the grace period. In this case, this contract will and on the later of:
1, the date stated in the notice; or
2. the date SafeGuard receives the notice.
If the Organization replaces this contract with another group contract but does not give SafeGuard notice
of Intent to end this contract, the grace period provisions will apply.
GPNP10•OHMO
25C-7
Page 5
END OF BENEFITS PROVIDED BY THIS CONTRACT
The Organization can end this contract by giving 60 days advance Written notice to SafeGuard. The
contract will end on the later of:
1. the date stated in'the notice; or
2. the date SafeGuard receives the notice.
SafeGuard can end this contract as follows:
1. on the date the Prepayment Fee Is not paid when due, subject to the Grace Period provisions; or
2. on any Prepayment Fee Due Date, by giving the Organization 31 days advance Written notice, if less
than:
a. for benefits for Members, 65% of persons eligible under this contract are Insured for Contributory
Benefits;
b. for benefits for Dependents, 75% of persons eligible under this contract who are not waiving
coverage due to coverage elsewhere, are insured for Contributory Benefits;
c. 100% of persons eligible under this contract are Insured for Noncontributory Benefits; or
d. 10 Members are insured by this contract.
3. on any Prepayment Fee Due Date, by giving the Organization 60 days advance Written notice, if the
Organization fails to provide Information on a timely basis or perform any obligations required by this
contract or any applicable law; or
4, on any Contract Anniversary, except during a Rate Guarantee Period as may be provided in the
Exhibits, by giving the Organization 31 days advance Written notice.
This contract will end on the date on which the last evidence of coverage In effect under this contract ends.
If this contract ends, all Prepayment Fees due must be paid. If SafeGuard accepts a Prepayment Fee
after the date this contract ends, such acceptance will not act to reinstate the contract. SafeGuard will
refund any unearned Prepayment Fee.
Within 30 days of the and of this contract, SafeGuard will refund to Organization the pro rata portion of
the Prepayment Fee which corresponds to any unexpired term for which a Prepayment Fee has been
received, together with any amounts due on claims, if any, less amounts due SafeGuard. SafeGuard
shall be paid the Prepayment Fee to the date this contract ends.
Notice of end of contract. If SafeGuard ends this contract, It will notify Organization In Writing and
Organization shall, within 5 calendar days, mail promptly to each Member a legible, true copy of the notice
of cancellation and shall provide SafeGuard proof of such mailing and the date thereof within 2 calendar
days of such mailing. Organization shall also have the obligation to provide notice to the Member
when this contract has actually been terminated within five (5) calendar days of such termination
Notice of cancellation of Covered Person's benefits. If, without ending the contract, SafeGuard
cancels a Covered Person's benefits under this contract because the Covered Person makes an
intentional misrepresentation or participates in fraud in the use of services or facilities, It will notify
Organization in Writing and Organization shall, within 5 calendar days, mail promptly to the Member a
legible, true copy of the notice of cancellation and shall provide SafeGuard proof of such mailing and the
date thereof within 2 calendar days of such mailing.
If Organization fails to provide such notices as required under this contract, SafeGuard will provide such
notices to the Members and will retain the right of recourse against Organization forfeiture to perform
under this contract.
GPNP10-DHMO
i
Page 61CA
REINSTATEMENT
Receipt by SafeGuard of a Prepayment Fee after cancellation of this contract for non-payment shall
reinstate this contract as though it had never been cancelled if a Prepayment Fee is received on or before
the due date of the succeeding Prepayment Fee.
The Organization may request to reinstate this contract within one year from the date It ended. The
request must be In Writing and It must provide SafeGuard with information that SafeGuard requires to
consider such request, if SafeGuard approves the request, the contract will be reinstated on the date
stated in Writing by SafeGuard.
GENERAL. PROVISIONS
Entire Contract. The entire contract is made up of the following;
1. this contract, including Its Exhibits;
2. the Organization's Application For Group Dental Benefits; and
3. the amendments and endorsements to this contract.
Contract Changes or Waivers. The terms and provisions of this contract may be changed, at any time,
without the consent of the Covered Persons or anyone else with a beneficial interest in it SafeGuard will
issue amendments and endorsements to effect such changes. SafeGuard will only make changes that
are consistent with applicable law. An amendment or endorsement will not affect the benefits provided
under evidences of coverage Issued before the effective date of the change, unless retroactivity Is
consistent with applicable taw.
An officer of SafeGuard must approve in Writing any change or walver of the terms and provisions of this
contract. A sales representative, or other SafeGuard employee, who is not an officer of SafeGuard, does
not have SafeGuard's authority to approve such changes or waivers. A change or waiver will be
evidenced by an amendment Signed by an officer of SafeGuard and the Organization or an endorsement
Signed by an officer of SafeGuard. A copy of the amendment or endorsement will be provided to the
Organization for attachment to this contract.
Incontestability: Statements Made by the Organization. Any statement made by the Organization will
be considered a representation and not a warranty. SafeGuard will not use such statement to avoid or
reduce benefits or defend a claim unless it is contained in a Written application.
Incontestability: Statements Made by Covered Persons. Any statement made by a Covered Person
will be considered a representation and not a warranty. SafeGuard will not use such statement to avoid or
reduce benefits or defend a claim unless the following requirements are met;
1. the statement is in a Written application or enrollment form;
2. the Covered Person has Signed the application or enrollment form; and
3. a copy of the application or enrollment form has been given to the Covered Person or his beneficiary.
SafeGuard will not use such statements to contest an Increase or benefit addition after the Increase or
benefit has been in force for 2 years during his life, unless the statement is fraudulent.
GPNP10-DHMO
25C-9
Page 7/CA
GENERAL PROVISIONS (continued)
Evidence of Coverage. SafeGuard will Issue an evidence of coverage to the Organization for delivery to
each Covered Person, as appropriate. The evidence of coverage will describe the Covered Person's
benefits and rights under this contract. "Evidence of coverage" Includes any of SafeGuard's schedules of
benefits, notices or other attachments to the evidence of coverage.
Participating Providers. The Directory of Participating Providers contains a complete listing of Selected
General Dental Offices. Selected General Dental Offices may also be located by accessing
www.metlife.com/mybenefits to view Selected Genera(Dental Offices by zip code.
SafeGuard will maintain a contractual relationship with dental facilities at appropriate locations to provide
services to Covered Persons. The Organization recognizes that the establishment maintenance and
location of all dental facilities are within the sale discretion of SafeGuard; and SafeGuard shall make the
scie determination of the location and establishment of a contractual relationship with all such dental
facilities. SafeGuard agrees to promptly notify Covered Persons and the Organization in writing of the
termination, breach of contract by, inability to perform of, or closure of any participating dental facility and
to transfer Covered Persons to existing or alternate dental facilities.
Assignment. The rights and benefits under this contract are not assignable prior to a claim for benefits,
except as required by law or as permitted by SafeGuard.
Data Needed. The Organization will provide SafeGuard with all the data needed to compute the
Prepayment Fee and cant' out the terms of this contract. SafeGuard may examine such data at any
reasonable time. If SafeGuard or the Organization make a clerical error In keeping the data, the
Prepayment Fee andlor benefits will be adjusted according to the correct data. An error will not end
benefits validly in effect, nor will It continue benefits validly ended.
Misstatement of Age. If a Covered Person's age is misstated, the correct age will be used to determine
if benefits are in effect and, as appropriate, adjust the Prepayment Fee and/or benefits.
Non -Dividend Paying. This contract does not pay dividends.
Conformity with Law. If the terms and provisions of this contract do not conform to any applicable law,
this contract shall be Interpreted to so conform.
GPNP10-DHMO
25C-1 0
Page 8
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above written.
ATTEST:
OF
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
By: &3"X .- N,
Laura A. Rossini
Senior Assistant City Attorney
RECOMMENDED FOR APPROVAL:
CITY OF SANTA ANA
Raul Godinez, II /fig
City Manager
SAFEGUARD HEALTH PLANS, INC.
(Name)
(Title)
El en Smiley
Assistant Executive irector of Personnel Services
25C-11
SCHEDULE OF EXHIBITS
Exhibit Effective
Number Exhibit Type Applies To Date
Prepayment Fee Schedule All Covered Persons January 1, 2017
Evidence of Coverage All Covered Persons January 1, 2017
Schedule of Benefit All Covered Persons January 1, 2017
GPNP10-DHMO SCHIEXHIBITS
25C-12
EXHIBIT 1
PREPAYMENT FEE SCHEDULE
The initial monthly Prepayment Fee for the benefits provided by this contract are determined as follows:
Rate Guarantee Period
Subject to the Right to Change the Prepayment Fee provision on page 4, the Prepayment Fee for
Speclalized Health Care Service Plan Benefits will be In effect from January 1, 2017 through December
31, 2017.
Specialized Health Care Service Plan Benefits;
Amount per unit for Specialized Health
Care Service Plan Benefits in force
hereunder
Member Only $27.70
Member and Family $47.34
GPNP10-DHMO DATE: January 1, 2017 EXHIBIT 1
25C-13
EXHIBIT 2
EVIDENCE OF COVERAGE FORMS
EOC Number EOC Form
1 - GOERT2011-DHMO-EOC
GPNP10-DHMO
Applies To
All Covered Persons -
DATE: January 1, 2017
25C-14
Effective Date
January 1, 2017
EXHIBIT 2
MetLife
Benefits Provided by SafeGuard Health Plans, Inc., a MetLife company
200 Park Avenue, New York, Now York 10166-0188
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE STATEMENT
SafeGuard Health Plans, Inc. ("SafeGuard"), a MetLife company, certifies that You and Your dependents are
covered for the benefits described in this evidence of coverage and disclosure statement , subject to the
provisions of this evidence of coverage. This evidence of coverage Is Issued to You under the group contract
and it Includes the terms and provisions of the group contract that describe Your benefits. PLEASE READ
THIS EVIDENCE OF COVERAGE CAREFULLY.
This evidence of coverage is part of the group contract. The group contract is a contract between SafeGuard
and Your Organization and may be changed or ended without Your consent or notice to You.
THIS EVIDENCE OF COVERAGE ONLY DESCRIBES DENTAL BENEFITS.
REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR
EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30
DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM
YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER
HAVE BEEN ISSUED,
WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE
AND IN THE NOTICE($) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S)
CAREFULLY.
OCERT2011-DHMO-EOC
25C-15
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
Continuation under a New Plan.................................................................................. 18
GENERALPROVISIONS..................................................................................................................................18
EntireContract................................................................................................................ 18
Incontestability: Statements Made by You.....................................................................................................18
Misstatementof Age...................................................................................................................................... 18
Conformitywith Law...................................................................................................................................... 18
PublicPolicy Committee................................................................................................................................ 18
DEFINITIONS....................................................................................................................................................19
GCERT2011-OHMO-EOC 26
C-17
NOTICE FOR RESIDENTS OF CALIFORNIA
This evidence of coverage provides a detailed summary of how your SafeGuard dental
contract operates, Your entitlements, and the contract's restrictions and limitations. This
combined evidence of coverage and disclosure statement constitutes only a
summary of the contract. The contract must be consulted to determine the exact
terms and conditions of coverage. If You have special health care needs, You should
read carefully those sections that apply to You. You may obtain a copy of the contract by
requesting it from the Organization, or by writing to SafeGuard Health Plans, Inc., Attn:
Legal Department, 5 Park Plaza, Suite 1850, Irvine, CA, 92614.2533, or by calling (800)
880-1800,
This evidence of coverage and disclosure statement is subject to Chapter 2.2 of Division 2 of the California
Health and Safety Code (commonly referred to as the Knox -Keene Act) and the regulations Issued thereto by
the Department of Managed Health Care, Should either the law or the regulations be amended, such
amendments shall automatically be deemed to be a part of this document and shall take precedence over any
inconsistent provision of this contract. Any provision required to be in this evidence of coverage and
disclosure statement by either law or the regulation shall automatically bind SafeGuard.
Pursuant to Section 1365(b) of the Knox -Keene Health Care Service Plan Act of 1975, as amended, an
enrollee or subscriber who alleges that his or her enrollment has been canceled or not renewed because of
his or her health status or requirements for health care services may request a review by the Director of
California Department of Managed Health Care. If the Director determines that a proper complaint exists, the
Director shall notify SafeGuard, Within 16 days after receipt of such notice, SafeGuard shall either request a
hearing or reinstate the enrollee or subscriber. If, after hearing, the Director determines that the cancellation
or failure to renew is improper, the Director shall order SafeGuard to reinstate the enrollee or subscriber. A
reinstatement pursuant to this provision shall be retroactive to the time of cancellation or failure to renew and
SafeGuard shall be liable for the expenses incurred by the subscriber or enrollee for covered health care
services from the date of cancellation or non -renewal to and including the date or reinstatement.
Confidentiality of Dental Records
A STATEMENT DESCRIBING SAFEGUARD'S POLICIES AND PROCEDURES FOR
PRESERVING THE CONFIDENTIALITY OF DENTAL RECORDS IS AVAILABLE AND
WILL BE FURNISHED TO YOU UPON REQUEST.
Organ Donation
Donating organs and tissues provides many societal benefits. Organ and tissue donation allows recipients of
transplants to go on to lead fuller and more meaningful lives, Currently, the need for organ transplants far
exceeds availability. If You are Interested in organ donation, please speak with Your physician. Organ
donation begins at the hospital when a person is pronounced brain dead and Is Identified as a potential organ
donor. An organ procurement group will become Involved to coordinate the activities,
Language Assistance
As a SafeGuard Member You have a right to free language assistance services, including Interpretation and
translation services. SafeGuard collects and maintains Your language preferences, race, and ethnicity so that
we can communicate more effectively with our Members. If You require spoken or Written language
assistance or would like to Inform SafeGuard of Your preferred language, please contact us at (800) 680-
1800,
fV%SafaGuard0*A, fes; t 1 # WMIT09ifil. SafeQu8rdl&fflWA11*ri
I Ol`! NSON, %in t" NS 't
� M ISM, a s i # A�1 Safedttard, f 9 ft i Safe uardll if , Wit
0(800) seem1840,
GCERT2011-DHMO-EOC 2
6l
Como miembro de SafeGuard usted tiene derecho a recibir servicios gratultos de asistencia an idiomes, Esto
incluye servicios de interpretaci6n y traducci6n, SafeGuard recaba Is information sobre sus preferenclas de
Idioms, raze, y etnia de manera qua nos podamos comunicar eficazments con nuestros afiliados. Si necesita
asistencia verbal o escrita an su idioma o qulere informarle a SafeGuard sobre su idioma de preferencla,
comunrquese con nosotras al (800) 880.1 Boo.
NOTICE FOR RESIDENTS OF ALL STATES
Notice Regarding Your Rights and Responsibilities
Bights:
• During the term of the group contract between SafeGuard and Your Organization, SafeGuard will not
decrease any benefits, increase any Co -Payment, or the Prepayment Fee, or change any exclusion or
limitation, except after at least 30 days Written notice to Your Organization.
• We will provide Written notice within a reasonable time to Your Organization of any termination or breach
of contract by, or Inability to perform of, any contracting provider if Your Organization may be materially
and adversely affected.
• We will not cancel or fall to renew Your enrollment in this group contract because of your health condition
or your requirements for dental cars.
• We will treat communications, financial records and records pertaining to Your care in accordance with all
applicable laws relating to privacy.
• Decisions with respect to dental treatment are the responsibility of You and Your Selected General
Dentist. We neither require nor prohibit any specified treatment. However.
• Only certain specified services are Covered Services. Please see the Schedule of Benefits. Please
also review the DENTAL BENEFITS section of this evidence of coverage for more details.
• Your Selected General Dentist must follow the rules and limitations set up by SafeGuard and conduct
his or her professional relationship with You within the guidelines established by SafeGuard. If
SafeGuard's relationship with Your Selected General Dentist ends, Your Selected General Dentist
must complete any and all treatment in progress, SafeGuard will arrange a transfer for You to
another Selected General Dentist to provide for continued coverage under the group contract. As
Indicated on Your enrollment form, Your signature authorizes SafeGuard to obtain copies of your
dental records, if necessary.
• You may request a response from SafeGuard to any Written concern or complaint.
Responsibilities:
• You should identify Yourself to Your Selected General Dentist as a covered person under the group
contract. If You fail to do so, You may be charged the Selected General Dentist's usual and customary
fees instead of the applicable Co -Payment, if any.
• You should treat the Selected General Dentist and his or her office staff with respect and courtesy and
cooperate with the prescribed course of treatment. If You continually refuse a prescribed course of
treatment, Your Selected General Dentist or Specialty Care Dentist has the right to refuse to treat You.
SafeGuard will facilitate second opinions and will permit You to change Your Selected General Dental
Office; however, SafeGuard will not interfere with the dentist -patient relationship and cannot require a
particular dentist to perform particular services.
• You should contact the Selected General Dental Office twenty-four (24) hours in advance to cancel an
appointment. If You do not, You may be charged a missed appointment fee.
• You are responsible for the prompt payment of any charges for services performed by the Selected
General Dentist. If the Selected General Dentist agrees to accept part of the payment directly from
SafeGuard, You are responsible for prompt payment of the remaining part of the Selected General
Dentist's charge.
GCERT2011-DHMO-EOC 25C-19
• You should notify SafeGuard of changes In family status. If You do not, SafeGuard will be unable to
authorize denial care for You andior Your dependents.
• You should consult with Your Selected General Dentist about treatment options, proposed and potential
procedures, anticipated outcomes, potential risks, anticipated benefits and alternatives. You should
share with Your Selected General Dentist the most current, complete and accurate Information about
Your medical and dental history and current conditions and medications.
• You should follow the treatment plans and health care recommendations agreed upon by Your Selected
General Dentist.
DENTAL BENEFITS
The group contract provides access to You and Your dependents to dental benefits through the use of
Selected General Dentists. When You or a dependent receive dental services; You and not Us or Your
Organization are solely responsible for payment of all Co -Payments and other charges listed in the Schedule
of Benefits and for any excluded procedure, and must make payment directly to the Selected General Dentist
rendering such services.
Dentist -Patient Relationship
We do not provide dental services. Whether or not benefits are available for a particular service does not
mean You or Your dependents should or should not receive the service. You and Your dependents, along
with the Selected General Dentist have the right and are responsible at all times for choosing the course of
treatment and services to be performed.
The relationship between You and Your dependents and the Selected General Dentist rendering services or
treatment shall be subject to the rules, limitations and privileges incident to the professional relationship, and
SafeGuard's Peer Review Committee and Public Policy Committees. The Selected General Dentist shall be
solely responsible to You or Your dependent, without Interference from SafeGuard or Your Organization, for
all services or treatment within the professional relationship, The Selected General Dentist shall have the
right to refuse treatment If You or Your dependents continually fall to follow a prescribed course of treatment,
use the relationship for Illegal purposes, or make the professional relationship onerous.
While SafeGuard desires and will actively seek to contract with the most modern dental facilities available in
the profession, it is understood and agreed that the operation and maintenance of the Selected General
Dentist's facility, equipment and the rendition of all professional services shall be solely and exclusively under
the control and supervision of the Selected General Dentist, including all authority and control over the
selection of staff, supervision of personnel, and operation of the professional practice and/or the rendition of
any particular professional service or treatment.
SafeGuard will undertake to see that the services provided to You or Your dependents by Selected General
Dentists shall be performed in accordance with professional standards of reasonable competence and skill of
dental practitioners, as applicable, prevailing in the community in which each Selected General Dentist
practices.
Upon termination of a provider contract with a Selected General Dentist, SafeGuard is liable for Covered
Services rendered by such provider (other than for Co -Payments) to You or Your dependents who remain
under the care of such provider at the time of such termination until the services being rendered are
completed, unless We make reasonable and medically appropriate provision for the assumption of such
services by another Selected General Dentist.
In the event of termination of this group contract, each Selected General Dentist shall complete all dental
procedures which have been started prior to the date of termination, pursuant to the terms and conditions of
this group contract.
Who May Enroll
Your Organization is responsible for determining eligibility. You may enroll Yourself and Your dependents,
provided each meets Your Organization's eligibility requirements and/or the Service Area and dependent
coverage requirements listed below.
GCERT2011-DHMO-BOC 2SC-20
SERVICE AREA
SafeGuard's service area is the geographic region In the state of California where SafeGuard is authorized by
the California Department of Managed Health Care to provide Covered Services to Members and in which
SafeGuard has a panel of Selected General Dentists and Specialty Care Dentists who have agreed to provide
care to SafeGuard members, To enroll in the SafeGuard plan, You and Your dependents must reside, live, or
work in the Service Area.
DEPENDENT COVERAGE
Your Organization Is responsible for determining dependent eligibility. In the absence of such a
determination, SafeGuard defines eligible dependents as:
• Your lawful Spouse or domestic partner;
• Your children or grandchildren up to age 26 for whom You provide care, including adopted children,
step-ohildren, or other children for whom You are required to provide dental care pursuant to a court
or administrative order;
• Your children who are incapable of self-sustaining employment and support due to a developmental
disability or physical handicap; and
• Other dependents if Your Organization provides benefits for these dependents,
Please checkwith Your Organization If you have questions regarding your eligibility requirements
WHEN COVERAGE BEGINS
Coverage for You and Your enrolled dependents will begin on the date determined by Your Organization.
Newborn children are covered the day of birth as long as You are enrolled; legally adopted children, foster
children and stepchildren are covered the first day of the month following placement as long as SafeGuard is
notified within ninety (90) days.
Your coverage will begin on the date determined by Your Organization. Waiting periods for eligibility, if
applicable, are determined by Your Organization.
Adopted child are covered from the earlier of the moment the child is placed in Your residence, and the child's
birth, if You have entered into a written agreement to adopt the child prior to its birth. Newborn children are
covered the first day of the month following the date of birth, and foster children and stepchildren are covered
the first day of the month following placement as long as Your Organization is notified within 90 days and any
Prepayment Fee is paid within that period.
Check with Your Organization if You have any questions about when Your coverage begins.
Choice of Dentists
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT
GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED.
When enrolling for dental benefits, You and Your dependents must choose a Selected General Dental Office
from Our network. You and Your dependents each may select a different Selected General Dental Office. if
You do not select a Selected General Dental Office or the one you chose is not available, SafeGuard may do
so for You. Please refer to the Directory of Participating Providers for a complete listing of Selected General
Dental Offices. You may obtain a Directory of Participating Providers from Our website www.metlife.00mk
mybenerits or by calling (800) 880-1800.
Facilities
You may obtain a list of SafeGuard's Selected General Dental Offices and their hours of availability by calling
SafeGuard at (800) 880-1800. A list of SafeGuard's participating General Dental Offices can be found it is
Directory of Participating Providers or online at www.metlife,comlmybenefits.
GCERT2011-DHMO-IEOC 26C-21
Changing Your Selected General Dental Office
You or Your dependent may change Selected General Dental Offices at any time. To do so, please contact
Us at (800) 880-1800. We will help You locate a convenient Selected General Dental Office. The transfer will
be effective on the first day of the month following the transfer request. There is no limit to how often You or
Your dependent may change Selected General Dental Offices, You must pay all outstanding charges owed
to Your or Your dependent's Selected General Dental Office before transferring to a new Selected General
Dental Office. You may also have to pay a fee for the cost of duplicating x-rays and dental records.
Provider Reimbursement
By statute, every contract between SafeGuard and its providers state that, in the event SafeGuard fails to pay
the provider, You shall not be liable to the provider for any sums owed by SafeGuard, Selected General
Dental Offices will collect all applicable co -payments from you directly at the time of service and then bill
SafeGuard for reimbursement according to the contracted plan provisions.
Selected General Dental Offices are paid on a per member, per month, or "capitated" basis for members that
have selected the Selected General Dental Office and may receive an additional or supplemental fee for
certain procedures performed. Specialty Care Dentists are compensated according to a negotiated fee
schedule. No bonuses or incentives are paid to Selected General Dental Offices or Specialty Care Dentists.
For additional information, you may contact SafeGuard at (800) 880-1800 or speak directly with Your
provider.
Liability of Subscriber or Enrollee for Payment
Covered Services must be performed by Your Selected General Dental Office or a Specialty Care Dentist to
whom You are referred in accordance with the terms of Your evidence of coverage and Schedule of Benefits.
Services performed by any Out -of -Network Dentist are not Covered Services, without prior approval by
SafeGuard or Your Selected General Dentist, in accordance with the terms of Your evidence of coverage and
Schedule of Benefits (except for out -of -area emergency services), If You or Your dependent self -refer to a
Selected General Dentist (other than Your or Your dependant's Selected General Dentist) or an Out -of -
Network Dentist, You are responsible for the cost of those services,
Prepayment Fee
Your Organization prepays Us for Your and Your dependent's coverage. If You are responsible for any
portion of this Prepayment Fee, Your Organization will advise You of the amount and how it is to be paid.
Please refer to the Co -Payment section, below, for information relating to Your Co -Payments under this group
contract. The Prepayment Fee is not the same as a Co -Payment.
The exact Prepayment Fee is contained in the group contract between Us and Your Organization. You may
obtain a copy of the group contract from Your Organization, or by writing to SafeGuard Health Plans, Inc.,
Attn: Legal Department, 5 Park Plaza, Suite 1850, Irvine, CA 92614.2533, or by calling (800) 880-1800.
Co -Payments
When You or Your dependent receive care from either a Selected General Dentist or a Specialty Care
Dentist, You must pay the Co -Payment. The Cc -Payment is a fixed dollar amount or a fixed percentage of
the Maximum Allowed Charge of the Covered Services performed by Your Selected General Dentist for which
We are not responsible, as shown in the Schedule of Benefits. When You or Your dependent are referred to
a Specialty Care Dentist, the Co -Payment may be either a fixed dollar amount, or a percentage of the
Maximum Allowed Charge. Please refer to the Schedule of Benefits for specific details. When You have paid
the required Co -Payment, if any, You have paid in full. If We fall to pay the Selected General Dentist, You will
not be liable to the Selected General Dentist for any sums owed by Us. If You or Your dependent choose to
receive services from an Out -of -Network Dentist, You will be liable to the Out-cf-Network Dentist for the cost
of services unless specifically authorized by Us or In accordance with Emergency Dental Condition provisions
of this evidence of coverage. We do not require claim forms.
GCSRT2011-DHMO-EOC 26C-2
2
Orthodontic Covered Services
Orthodontic treatment Is governed by the Schedule of Benefits. If Dental Benefits terminate after the start of
Orthodontic treatment, You will be responsible for any additlonal incurred charges for any remaining
Orthodontic treatment.
Yearly Maximums
The Schedule of Benefits lists the Yearly maximums for Covered Services, if applicable,
Covered Services After Dental Coverage Ends
Dental services received after You or Your dependent's coverage terminates are not covered. Your Selected
General Dentist must complete any dental procedure started on you before your termination, abiding by the
terms and conditions of the plan.
Orthodontic treatment is governed by the Orthodontic limitations listed in the Schedule of Benefits, If
coverage from the plan ends after the start of Orthodontic treatment, You or Your dependent will be
responsible for any costs Orthodontic treatment after coverage ends,
Non -Covered Services
IMPORTANT: If you opt to receive dental services that are not covered services under this plan, a
participating dental provider may charge you his or her usual and customary rate for those services. Prior to
providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient
a treatment plan that Includes each anticipated service to be provided and the estimated cost of each service.
If you would like more information about dental coverage options, you may call member services at (800) 880-
1800 or your insurance broker. To fully understand your coverage, you may wish to carefully review this
evidence of coverage.
Other Charges
All other charges You may be required to pay under this evidence of coverage are listed in the Schedule of
Benefits. You must pay all Co -Payments, or the percentage of the Maximum Allowed Charge that We are not
responsible for under the group contract.
Reimbursement Provisions
You are financially responsible for the cost of any services received from Out -of -Network Dentist unless those
services were arranged by Your or Your dependent's Selected General Dentist or were required to treat an
Emergency Dental Condition.
When You or Your dependent receive a Covered Service from an Out -of -Network Dentist for an Emergency
Dental Condition, You should request that the Out -of -Network Dentist bill Us. If the Dentist refuses to bill Us
but agrees to bill You, You should immediately submit the bill to Us In accordance with the sub -section titled
Emergency Dental Care.
If you receive a bill or have paid for a Covered Service and seek reimbursement, please contact SafeGuard at
(800) 880-1800. Once you have paid your Co -Payments for Covered Services at Your Selected General
Dentist Office, you are no responsible for any other payments for Covered Services,
Specialty Care Referrals
During the course of treatment, Your Selected General Dentist may encounter situations that require the
services of a Specialty Care Dentist. Your Selected General Dentist is responsible for determining when the
services of a Specialty Care Dentist are necessary. How Specialty Care is accessed Is determined by Your
plan. Some plans allow self -referral while others require that Your Selected General Dentist refer You directly
to a provider whose practice is limited to Specialty Care, Please consult the Schedule of Benefits for full
information.
GCERT2011-DHMO-EOC 25C-23 9
Second Opinion
You or Your dependent may request a second opinion If there are unanswered questions about diagnosis,
treatment plans, and/or the results achieved by such dental treatment. In addition, We or You or Your
dependents Selected General Dentist may also request is second opinion. There Is no second opinion
consultation charge. You or Your dependent will be responsible for the office visit Co -Payment as listed in the
Schedule of Benefits.
Reasons for a second opinion to be provided or authorized shall Include, but are not limited to, the following:
(1) If You or Your dependent question the reasonableness or necessity of recommended surgical
procedures.
(2) If You or Your dependent question a diagnosis or plan of care for a condition that threatens loss of
life, loss of limb, loss of bodily function, or substantial impairment, including, but not limited to, a
serious chronic condition.
(3) If the clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to
conflicting test results, or the treating Selected General Dentist is unable to diagnose the condition,
and the enrollee requests an additional diagnosis.
(4) If the treatment plan In progress is not improving Your or Your dependents dental condition within an
appropriate period of time given the diagnosis and plan of care, and You or Your dependent request
a second opinion regarding the diagnosis or continuance of the treatment
Requests for second opinions are processed within five (6) business days of Our receipt of such request,
except when an expedited second opinion is warranted; in which case a decision will be made and conveyed
to You within twenty-four (24) hours. Upon approval, We will contact the consulting Selected General Dentist
and make arrangements to enable You or Your dependent to schedule an appointment.
All second opinion consultations will be completed by a Selected General Dentist with qualifications in the
same area of expertise as the referring Selected General Dentist or Selected General Dentist who provided
the Initial examination or dental care services.
You or Your dependent may request a second opinion or obtain a copy of the second dental opinion policy by
contacting Us either by calling (800) 880.1800 or sending a written request to the following address:
SafeGuard
c/o Customer Service
Pt} Sox 3694
Laguna Hills, CA 92864-3694
Emergency Dental Care
Emergency Dental Care means dental screening, examination, and evaluation by a Dentist, or, to the extent
permitted by applicable law, by appropriate personnel under the supervision of a Dentist to determine if an
Emergency Dental Condition exists, and, if it does, the care and treatment necessary to relieve or eliminate
the Emergency Dental Condition.
All Selected General Dental Offices provide treatment for Emergency Dental Conditions twenty-four (24)
hours a day, seven (7) days a week and We encourage You or Your dependent to seek care from Your
Selected General Dental Office. If treatment for an Emergency Dental Condition is required, You or Your
dependent may go to any dental provider, go to the closest emergency room, or call 911 for assistance, as
necessary. Prior authorization is not required.
Your reimbursement from Us for treatment for an Emergency Dental Condition, if any, is limited to the extent
the treatment You or Your dependent received directly relates to the evaluation and stabilization of the
Emergency Dental Condition. All reimbursements will be allocated in accordance with the group contract,
subject to any exclusions and limitations, Hospital charges and/or other charges for care received at any
hospital or outpatient care facility are not Covered Services.
If You or Your dependent receive treatment for an Emergency Dental Condition, You will be required to pay
the charges to the Dentist and submit a claim to Us for a benefits determination. If You or Your dependent
seek treatment for an Emergency Dental Condition from a provider located more than fifty (60) miles away
GCERT2011•DI-11111 EttC 25C-24 10
from Your or Your dependent's Selected General Dentist, You or Your dependent will receive coverage for
the treatment of the Emergency Dental Condition up to a maximum of fifty dollars ($50).
To be reimbursed for treatment of an Emergency Dental Condition, You must notify Us after receiving such
treatment. If You or Your dependent's physical condition does not permit such notification, You must make
the notification as soon as it is reasonably possible to do so, Please include your name, ID number of the
person who received treatment, address and telephone number on all requests for reimbursement.
If You or Your dependent do not have an Emergency Dental Condition and a delay In receiving treatment
would not be detrimental to Your or Your dependent's health, please contact Your or Your dependent's
Selected General Dental Office or Our Customer Service Department at (800) 880-1800 to make reasonable
arrangements for Your or Your dependent's care.
TERMINATION OF BENEFITS
Cancellation of Benefits
Your coverage may be cancelled for any reason, after not less than sixty (80) days Written notice by either
SafeGuard or Your Organization.
Your coverage may be cancelled after not less than thirty (30) days Written notice for:
• Non-payment of amounts due under the contract, except no Written notice will be required for failure to
pay premium.
• Failure to establish a satisfactory Dentlst-patient relationship and if it Is shown that SafeGuard has, in
good faith, provided You with the opportunity to select an alternative Dentist,
• Failure to reside, live or work in the Service Area.
Your coverage may be cancelled for not less than fifteen (15) days Written notice for:
• An intentional misrepresentation, except as limited by statute,
• Fraud in the use of services or facilities, or on the part of Your Organization.
• Such other good cause as agreed upon in the group contract.
Your coverage may be cancelled Immediately:
• Subject to any continuation of coverage and conversion privilege provisions, if applicable, if You do not
meet eligibility requirements other than the requirements that You live, work or reside in the Service Area.
• Upon termination of the group contract between SafeGuard and Your Organization, if expired and not
renewed.
If Your Organization fails to pay the Prepayment Fees through and including the final month of the group
contract, all coverage may be terminated at the end of the group contract's grace period, and You may be
responsible for the usual and customary fees for any services received from Your Selected General Dentist or
Specialty Care Dentist during the period the Prepayment Fees went unpaid, including the group contract's
grace period.
If You terminate from the plan while the contract between SafeGuard and Your Organization is in effect, Your
coverage will extend to the end of the month following notice of termination. Your Selected General Dentist
must complete any dental procedures started on You before Your termination, abiding by the terms and
conditions of the plan.
Your and Your dependents' enrollment will be cancelled as of the last day for which Prepayment Fees have
been received, subject to compliance with notice requirements.
In the event Your and Your dependents' enrollment Is cancelled, SafeGuard will send such notification to Your
Organization, which will, in turn, notify You. Your Organization will also send You notice when Your actual
coverage Is terminated.
GCERT2011-DHMO-EOC 26C-25 11
Orthodontic treatment is governed by the Orthodontic limitations listed on Your Schedule of Benefits. If You
terminate coverage from the plan after the start of Orthodontic treatment, You will be responsible for any
additional incurred charges for any remaining Orthodontic treatment.
Renewal Provisions
Your Organization has contracted with SafeGuard to provide services for the time period specified in the
group contract. Your coverage under the plan is guaranteed for that time period so long as You meet the
eligibility requirements under the plan, When the group contract expires, it may be renewed. If renewed, It is
possible that the terms of the plan may have been changed, if changes to Covered Services, Co -payments
or Your contribution to the Prepayment Fees have been made to a renewed contract, Your Organization will
notify You not less than thirty (30) days before the effective date,
Reinstatement
Receipt by SafeGuard of the proper prepaid or periodic payment after cancellation of the contract for non-
payment shall reinstate the contract as though It had never been cancelled if such payment is received on or
before the due date of the succeeding payment.
A Member who alleges that his or her enrollment has been cancelled or not renewed because of his or her
health status or requirements for health care services may request a review by the Director of the California
Department of Managed Health Care. If the Director determines that a proper complaint exists, the Director
shall notify SafeGuard. Within fifteen (18) days after receipt of such notice, SafeGuard shalt either request a
hearing or reinstate the person as a Member. If, after the hearing, the Director determines that the
cancellation or failure to renew Is Improper, the Director shall order SafeGuard to reinstate the person as a
Member. A reinstatement pursuant to this provision shall be retroactive to the time of cancellation or failure to
renew and SafeGuard shall be liable for the expenses incurred by the subscriber or enrollee for covered
health care services from the date of cancellation or non -renewal to and including the date of reinstatement.
Disenrollment
You may disenroll from the plan at the end of the term of the group contract, Please contact Your
Organization for more information.
CONTINUITY OF CARE
Current Members
If You are a current Member of SafeGuard, You may be eligible to temporarily continue receiving Covered
Services for You and/or Your dependents from a former Selected General Dentist Office or Specialty Care
Dentist whose Contract with SafeGuard is terminated (a "Terminated Provider") for treatment of certain
specified dental conditions. Please call SafeGuard at (800) 880-1800 to see if You are eligible for this benefit.
You may request a copy of SafeGuard's Continuity of Care Policy from SafeGuard. You must make a specific
request to continue under the care of a Terminated Provider, SafeGuard Is not required to continue Your care
with Your Terminated Provider if You are not eligible under SafeGuard's Continuity of Care Policy or if
SafeGuard cannot reach agreement with the Terminated Provider on the terms regarding Your and/or Your
dependents' care in accordance with California law,
New Members
If You are a new Member of SafeGuard, You may be eligible to temporarily continue receiving Covered
Services for You and Your dependents from an Out -of -Network Dentist for treatment of certain specified
conditions if the services were being provided by an Out -of -Network Dentist at the time the Your coverage
becomes effective. Please call SafeGuard at (800) 880-1800 to see If You may be eligible for this benefit.
You may request a copy of SafeGuard's Continuity of Care Policy from SafeGuard. You must make a specific
request to continue under the care of the Out -of -Network Dentist. SafeGuard is not required to continue care
with the Out -of -Network Dentist if You are not eligible under SafeGuard's Continuity of Care Policy or if
SafeGuard cannot reach an agreement with the Out -of -Network Dentist on the terms regarding Your for You
and Your dependents care in accordance with California law.
GCERT2011-DHMO-ECC 25C-26 12
DENTAL BENEFITS: INQUIRIES AND GRIEVANCE PROCEDURES
Routine Questions About Dental Benefits
If You have any questions about dental benefits provided by the group contract, please call Us at (800) 880-
1600.
Grievance Procedures
If You or Your dependents have a grievance with Us or Your Selected General Dentist, You may submit such
grievance by calling Our customer service department at (800) 880-1800. When You call, You may:
• submit the grievance orally, or
• request a grievance form to submit the grievance in Writing.
To submit the grievance in Writing, complete the grievance form, or provide a detailed summary of Your
grievance to:
SafeGuard
c/o Quality Management Department
PC Box 3532
Laguna Hills, CA 82654-3532
You may also file a Written grievance via our website at www.metlife,com/mybeneflts. Please click on
Members, then "Forms to Print," and then "Grievance Forms".
In all Written correspondence, please be sure to Include at least the following information:
• Your name,
• Name of the Plan,
• Identification Number of the person You are Writing about; and
• Facility (or Selected General Dental Office) name and number.
We agree to Investigate and try to resolve complaints received. We will confirm receipt of Your complaint in
writing within five (5) calendar days of receipt. We will resolve the complaint and communicate the resolution
in writing within thirty (30) calendar days, A grievance must be filed within one hundred and eighty (180) days
of the occurrence or incident that is the subject of the grievance.
If Your grievance involves an Imminent and serious threat to Your health, including but not limited to severe
pain, potential loss of life, limb or major bodily function, You or Your provider may request an expedited
review, and if Your grievance qualifies as an urgent grievance, We will process Your grievance within three
(3) calendar days from receipt of Your request. You are not required to file a grievance with SafeGuard
before asking the California Department of Managed Health Care ("Department") to review Your case on an
expedited basis. The Department may be contacted at (1-888-HMO.2219), TDD line (1-877-688-8891)
for the hearing and speech impaired, or http:flwww.hmohelp.ca.gov.
The California Department of Managed Health Care ("Department") is responsible for regulating health care
service plans. If You have a grievance against Your health plan, You should first telephone Your health plan
at (800) B80-1800 and use Your health plan's grievance process before contacting the Department. Using this
grievance procedure does not prohibit any potential legal rights or remedies that may be available to You. If
You need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved
by Your health plan, or a grievance that has remained unresolved for more than sixty (60) days, You may call
the Department for assistance. You may also be eligible for an Independent Medical Review ("IMR"). If You
are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health
plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments
that are experimental or investigational in nature and payment disputes for emergency or urgent medical
services. The Department also has a toll-free telephone number (1 -888 -HMO -2219) and a TDD line (1-
GCERT2011-DHMO-EOC •L5C-27 13
877-688-9891) for the hearing and speech Impaired. The Department's Internet Web Site
http://wwwr,hmohelp.ca.gOv has complaint forms, [MR application forms and Instructions online.
Arbitration
Each and every disagreement, dispute or controversy which remains unresolved concerning the construction,
Interpretation, performance or breach of this contract, or the provision of dental services under this contract
after exhausting SafeGuard's complaint procedures, arising between the Organization, a Member or the heir-
at-law or personal representative of such person, as the case may be, and SafeGuard, its employees, officers
or directors, or Selected General Dentist or their dental groups, partners, agents, or employees, may be
voluntarily submitted to arbitration in accordance with the American Arbitration Association rules and
regulations, whether such dispute involves a claim in tort, contract or otherwise. This Includes, without
limitation, all disputes as to professional liability or malpractice, that is as to whether any dental services
rendered under this contract were unnecessary or unauthorized or were Improperly, negligently or
Incompetently rendered. It also Includes, without limitation, any act or omission which occurs during the term
of this contract but which gives rise to a claim after the termination of this contract. Arbitration shall be
initiated by Written notice to SafeGuard at 5 Park Plaza, Suite 1850, Irvine, CA, 92614-2633.
Coordination of Benefits
We do not coordinate benefits with any other carrier, If You have coverage with another carrier, please
contact that carrier to determine whether coordination of benefits Is available.
Third Party Liability
If benefits covered by the group contract or evidence of coverage are provided to treat an Injury or illness
caused by the wrongful act or omission of another person or third party, provided that You are made whole for
all other damages resulting from the wrongful act or omission before SafeGuard is entitled to reimbursement.
You shall:
• Reimburse SafeGuard for the reasonable cost of services paid by SafeGuard to the extent permitted
under California Civil Code section 3040 immediately upon collection of damages by You, whether by
action or law, settlement or otherwise; and
• Fully cooperate with SafeGuard's effectuation of its lien rights for the reasonable value of services
provided by SafeGuard to the extent permitted under California Civil Code section 3040.
SafeGuard's lien may be filed with the person whose act caused the injuries, his or her agent, or the
court.
SafeGuard shall be entitled to payment, reimbursement, and subrogation in third party recoveries and You
shall cooperate to fully and completely effectuate and protect the rights of SafeGuard, Including prompt
notification of a case involving possible recovery from a third party.
Assignment of Benefits
By accepting coverage under the group contract, You agree to cooperate In protecting the Interest of
SafeGuard under this provision and to execute and deliver to SafeGuard or Its nominee any and all
assignments or other documents which may be necessary.or proper to fully and completely effectuate and
protect the rights of SafeGuard or its nominee, You also agree to fully cooperate with SafeGuard and not
take any action that would prejudice the rights of SafeGuard under this provision.
INDIVIDUAL CONTINUATION OF DENTAL BENEFITS WITH PAYMENT OF THE
PREPAYMENT FEE
For Mentally Or Physically Handicapped Children
Benefits for a dependent child may be continued past the age limit if the child Is incapable of self-sustaining
employment because of a mental or physical handicap as defined by applicable law. Proof of such handicap
GCERT2011-DHMO-EOC 266-20 14
must be sent to Us within thirty-one (31) days after the date the child attains the age limit and at reasonable
Intervals after such date.
Subject to the TERMINATION OF BENEFITS section, benefits will continue while such child:
• remains incapable of self-sustaining employment because of a mental or physical handicap; and
• continues to qualify as a child, except for the age limit.
For Family And Medical Leave
Certain leaves of absence may qualify under the Family and Medical Leave Act of 1993 (FMLA) for
continuation of benefits, Please contact the Organization for information regarding the FMLA.
At The Organization's Option
Your Organization may elect to continue beneffts by paying the Prepayment Fee for any of the reasons
specified below. Please check with Your Organization if You have questions regarding continuation. If Your
benefits are continued, benefits for Your dependents may also be continued. You will be notified by Your
Organization how much You will be required to contribute.
1. For the period You are laid off, up to two (2) months.
2. For the period You are not at work due to injury or sickness, up tonina (9) months.
3. For the period You are not at work due to any other Organization approved leave of absence; up to two
(2) months.
At the end of any of the continuation periods listed above, Your benefits will be affected as follows:
• if You return to work within these time periods, Your coverage will continue under the group contract;
• if You do not return to work within these time periods, Your employment will be considered to end and
Your benefits will end.
If Your benefits end, Your dependents' benefits will also end.
COBRA CONTINUATION FOR DENTAL BENEFITS
The following applies to employers with 29 or more employees that are not church or government
plans:
If Dental Benefits for You or a dependent end, You or Your dependent may qualify for continuation of such
benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA),
Please contact Your Organization for information regarding continuation of insurance under COBRA.
Cal -Cobra Continuation For Dental Benefits
If dental benefits for You or a dependent ends, You or Your dependent may qualify for continuation of such
benefits under Cal -Cobra, section 1366.20 of the California Health and Safety Code.
Events that Allow Continuation, and Length of Continuation
You and Your dependent may continue dental benefits under this plan for a period of up to thirty-six (35)
months, if Your dental benefits would otherwise end because:
1. Your employment ends for any reason other than Your gross misconduct, or
2. Your hours worked are reduced.
Your Organization must notify us of Your termination or reduction of hours within thirty-one (31) days after
Your termination or reduction of hours.
GCERT2011-DHM0-EOC 266-29 16
Your dependent may continue coverage under this plan for up to thirty-six (36) months If Your dependent's
dental benefits would otherwise end because of:
1. Your divorce,
2. Your legal separation,
3. Your death or
4. Your becoming eligible for Medicare.
Also, Your dependent child may continue coverage under this plan for up to thirty-slx (36) months if such
child's benefits would otherwise and because that child no longer qualifies as a dependent under the terms of
this plan.
New Dependents
During the continuation period, a child of Yours that is;
1, born;
2, adopted by You; or
3. placed with You for adoption;
will be treated as if the child were a dependent at the time benefits were lost due to an event described
above. To obtain benefits for the child, You must enroll the child for coverage within thirty (30) days of birth,
adoption or placement for adoption.
Termination of Coverage
With respect to each person who continues benefits, the continued benefits will end on the earliest of..
1. the end of the thirty-six (36) month continuation period;
2, the date of expiration of the last period for which the required payment was made;
3. the date this plan or coverage for Your class is cancelled;
4. the date the person becomes entitled to Medicare;
B. the date the person becomes covered by another group benefit plan that does not have an exclusion or
limitation for preexisting conditions that applies to the person;
6. the date the person becomes covered or could become covered by Federal Cobra (Section 4980B of the
United States Internal Revenue Code);
7. the date the person becomes covered or could become covered under a plan governed by Chapter 6A of
the Public Health Service Act, 42 U.S.C. Section 300bb-1 at seq., relating to Requirements for Certain
Group Health Plans for Certain State and Local Employees;
8. The first day of the first month that begins more than thirty-one (31) days after the date of final
determination under Title I or Title XVI of the Social Security Act that the person is no longer disabled.
Notice and Election of Coverage
When You or Your dependents become entitled to continue benefits under the plan because of.
1. Your termination or
2. Your reduction of hours worked,
We will send You, at Your last known address, the necessary Prepayment Fee information and enrollment
forms and disclosures within fourteen (14) days. You or Your dependents, will then have sixty (60) days to
elect to continue benefits from the latest of:
1. the date of the event that gives a right to continue coverage;
GCERT2011-DHMO-GOC 255-30 16
2. the date You are given notice of a right to continue coverage; and
S. the date coverage under this plan ends.
When You or Your dependents become entitled to continue benefits under the plan because of.
1, Your or Your dependent's receipt of determination of disability under the terms of the Social Security Act;
2. Your dependent child's ceasing to qualify as a dependent under this plan;
3. Your divorce;
4. Your legal separation;
5. Your death; or
6. Your becoming eligible for Medicare;
You or Your dependent must notify us within sixty (60) days. If We do not receive notice within sixty (60)
days, the person or persons who would otherwise have been entitled to continued benefits will be disqualified
from having dental benefits continued. You or Your dependent's notice and request for continued benefits
must be in Writing and delivered to Us by first class mail or other reliable means of delivery including personal
delivery, express mall, or private courier company.
Cost of Continued Coverage
Any person who elects to continue coverage under the plan must pay not more than one -hundred and ten
percent (110°/x) of the full cost of that benefits (including both the share You now pay and the share Your
Organization now pays).
Payment of the Prepayment pees
The first Prepayment Fee must be paid within forty-five (45) days of Your election to continue benefits. Your
first payment of the Prepayment Fee must be sufficient to pay all required Prepayment Fees and all
Prepayment Fees due. The Prepayment Fee payment must be sent to Us by first class mail, certified mail or
other reliable means of delivery, including personal delivery, express mail or private courier company. After
the first Prepayment Fee payment, Your payments for continued coverage must be made on the first day of
each month in advance. Failure to submit the correct Prepayment Fee amount within the forty-five (45) day
period will disqualify the person(s) to whom the Prepayment Fee relates from receiving continuation
coverage.
Exceptions
This right to continue coverage under this plan does not apply:
1. to a person who Is not a resident of California;
2, to a person who is covered by or eligible to be covered by Medicare;
3. to a person who is covered or who becomes covered by another group benefit plan that does not have an
exclusion or limitation for preexisting conditions that applies to the person;
4. to a person who is covered, becomes covered, or could become covered by Federal Cobra (Section
49608 of the United States Internal Revenue Code);
5. to a person who is covered, becomes covered, or could become covered under a plan governed by
Chapter 6A of the Public Health Service Act, 42 U.S.C. Section 300bb-1 et seq., relating to Requirements
for Certain Group Health Plans for Certain State and Local Employees;
6. to a person who fails to meet any one or more of the time limits set forth above for notice and election of
coverage;
7. to a person who fails to submit the correct Prepayment Fee when or before it is due;
8. if at the time coverage under this plan ends Your Organization has twenty (20) or more employees; or
9. if Your Organization fails to notify Us of Your termination or reduction in hours within thirty-one (31) days.
GCERT2011-DHMO-EOC 250-31 t7
Continuation under a New Plan
Your Organization must notify each person who has continued benefits under this plan if this plan ends for
any reason and Is replaced by Your Organization with a new group plan. The notice must be given thirty (30)
days before this plan ends. The notice will be sent to the last known address of the person who has continued
coverage under this plan, If this plan ends, continued benefits under this plan will end. A person who has
continued benefits under this plan may then elect similar coverage under Your Organization's new group plan,
If any, for the balance of the period that the person would have remained covered under this plan. Continued
benefits will end for that person if the person does not, within thirty (30) days of receiving notice that this plan
has ended, enroll in the new plan and pay any required contribution to the cost of the new plan. Your
Organization will provide benefit and contribution information, enrollment forms and instructions for enrolling
In the new plan. This information will be sent to the last known address of the person who has a right to
continue benefits. If Your Organization or any successor Organization or purchaser of Your Organization
ceases to provide a similar group benefit plan to active employees, the right to continue benefits ends,
GENERAL PROVISIONS
Entire Contract
Your dental benefits are provided under a group contract with Your Organization, The entire contract with
Your Organization is made up of the following:
1. the group contract and Its Exhibits, which include the evidence of coverage and Schedules of
Benefits;
2. Your Organization's application; and
3. any amendments and/or endorsements to the group contract.
Incontestability: Statements Made by You
Any statement made by You will be considered a representation and not a warranty. We will not use such
statement to avoid or reduce benefits or defend a claim unless the following requirements are met:
1, the statement is in a Written application or enrollment form;
2. You have Signed the application or enrollment form; and
3, a copy of the application or enrollment form has been given to You or Your Beneficiary.
Misstatement of Age
If Your or Your dependent's age Is misstated, the correct age will be used to determine eligibility for dental
benefits and, as appropriate, We will adjust the benefits and/or premiums.
Conformity with Law
If the terms and provisions of this evidence of coverage do not conform to any applicable law, this evidence of
coverage shall be interpreted to so conform.
Public Policy Committee
The Public Policy Committee (°Committee") provides Our clients with the opportunity to participate in the
review of quality improvement activities. Representatives of group contractholders, Selected General
Dentists and Specialty Care Dentists, and Our employees, meet quarterly to discuss quality improvement
activities and policies. if You are Interested in being a representative to the Committee meeting, please
contact Us at (800) 880-1800 and ask for the Director of Quality Management.
GCERT2011-OHMO-EOC 26C-32 18
DEFINITIONS
As used in this evidence of coverage, the terms listed below will have the meanings set forth below. When
defined terms are used in this evidence of coverage, they will appear with initial capitalization. The plural use
of a term defined in the singular will share the same meaning,
Amalgam means a silver filling material usually used an posterior teeth.
Anterior means teeth located in the front of the mouth — upper and lower six (B) teeth with three in each
Quadrant of the mouth; twelve (12) teeth In total.
Asymptomatic means without symptoms, the absence of any indication of disease, surrounding pathology or
impaired function.
Bicuspid means teeth located immediately In front of the molar teeth — upper and lower with two in each
Quadrant of the mouth; eight (8) teeth in total.
Bridge or Bridgework means a fixed replacement for one or more missing teeth that is permanently attached
to the teeth adjacent to the empty space(s).
Cast Restoration means an inlay, onlay, or crown.
Co -Payment or Co -Pay means a fixed dollar amount or a fixed percentage of the Maximum Allowed Charge
of the Covered Services performed by Your Selected General Dentist, for which We are not responsible, as
shown in the Schedule of Benefits. You must pay Your Co -Payment at the time of delivery of supplies or
services.
Cosmetic means services performed solely for appearance. Treatment of decay, disease or injury to the
teeth or supporting tissues of the teeth is not evident Cosmetic means any procedure which is directed at
improving the patient's appearance and does not meaningfully promote the proper function or prevent or treat
Illness or disease.
Covered Service means a dental service used to treat Your orYcur dependents dental condition which is:
• prescribed or performed by a Dentist while such person is covered for dental benefits;
• Dentally Necessary to treat the condition; and
• described in the Schedule of Benefits, or
• Dental Benefits sections of this evidence of coverage.
Crown means a restoration place over a tooth to strengthen andfor replace missing tooth structure. A crown
can be made of different materials, for example, noble, high noble, and base metals, or porcelain or porcelain
and metal.
Dental Hygienist means a person trained to:
• remove calcareous deposits and stains from the surfaces of teeth; and
• provide information on the prevention of oral disease,
The term does not include;
• You;
• Your Spouse; or
• any member of Your immediate family including Your and/or Your Spouse's parents; children
(natural, step or adopted); siblings; grandparents; or grandchildren.
Dentally Necessary means that a dental service or treatment is performed in accordance with generally
accepted dental standards and Is:
• necessary to treat decay, disease or injury of the teeth; or
• essential for the care of the teeth and supporting tissues of the teeth.
GCERT2011-DHMO-EOC 25C-33 19
Dentist means:
• a person licensed to practice dentistry in the Jurisdiction where such services are performed; or
• any other person whose services, according to applicable law, must be treated as Dentist's
services for purposes of the group contract. Each such person must be licensed In the
Jurisdiction where the services are performed and must act within the scope of that license. The
person must also be certified and/or registered if required by such Jurisdiction.
• For purposes of dental benefits, the term will include a physician who performs a Covered
Service,
The term does not include;
• You;
• Your spouse; or
• any member of Your immediate famlly including Your and/or Your spouse's parents; children
(natural, step or adopted); siblings; grandparents; or grandchildren.
Dentures means fixed partial dentures (bridgework), removable partial dentures and removable full dentures.
Directory of Participating Providers means the list of Selected General Dentists from whom You must
select to receive Covered Services.
Domestic Partner means each of two people, of the same or opposite sex, one of whom is an employee of
Your Organization, who represent themselves publicly as each other's domestic partner and have:
• registered as domestic partners with a government agency or office where such registration is
available; or
• submitted a domestic partner declaration to Your Organization.
The domestic partner declaration must establish that:
• each person Is 18 years of age or older;
• neither person is married;
• neither person hes had another domestic partner within 6 months prior to the date they enrolled for
insurance for the Domestic Partner under the Group Policy;
• they have shared the same residence for at least 6 months prior to the date they enrolled for
insurance for the Domestic Partner under the Group Policy;
• they are not related by blood in a manner that would bar their marriage in the jurisdiction in which
they reside;
• they have an exclusive mutual commitment to share the responsibility for each other's welfare and
financial obligations which commitment existed for at least 6 months prior to the date they enrolled for
insurance for the Domestic Partner under the Group Policy, and such commitment is expected to last
indefinitely; and
• 2 or more of the following exist as evidence of joint responsibility for basic financial obligations:
• a joint mortgage or lease;
• designation of the Domestic Partner as beneficiary for life insurance or retirement benefits;
• joint wills or designation of the Domestic Partner as executor and/or primary beneficiary;
• designation of the Domestic Partner as durable power of attorney or health care proxy;
• ownership of a joint bank account, joint credit cards or other evidence of joint financial
responsibility; or
• other evidence of economic interdependence.
Your Organization will review the declaration and determine whether to accept the request to insure the
Domestic Partner,
Your Organization will inform the employee of its decision.
GCERT2011-DHMO-EOC 25C_34 20
Emergency Dental Condition means a dental condition the onset of which is sudden, that manifests itself by
symptoms of sufficient severity, including, but not limited to, bleeding, swelling or severe pain, that a prudent
layperson, possessing an average knowledge of dentistry and health, could reasonably expect the absence of
Immediate dental attention to result in:
• placing the health of the person afflicted with such condition in serious jeopardy;
• serious Impairment to such person's bodily functions;
• serious impairment or dysfunction of any bodily organ or part of such person; or
• serious disfigurement of such person.
Endodontics means procedures that treat the nerve or the pulp of the tooth. These procedures are usually
needed due to injury or Infection of the tooth,
Experimental means services that do not have endorsement from professional organizations whose role is to
evaluate such Items. Services that are either unproven for the diagnosis or treatment of a condition or not
generally recognized by the professional community as effective or appropriate for the diagnosis or treatment
of a condition.
Maximum Allowed Charge means the lesser of:
• the amount charged by the Selected General Dentist or;
the maximum amount which the Selected General Dentist has agreed with Us to accept as
payment in full for the dental service.
Member means an Individual enrolled in the Safeguard dental plan,
Oral Surgery means surgery performed in and around the mouth, to remove teeth, reshape portions of the
bone or soft tissue, or biopsy suspect areas of the mouth.
Organization means an employer or other entity that has contracted with Us to arrange for the provision of
dental care benefits.
Orthodontics means braces and other procedures or appliances to help align the upper and lower teeth.
Out -of -Network Dentist means a Dentist who does not have a contractual agreement with Us to provide
Covered Services to You or a dependent
Periodontics means procedures related to treatment of the supporting structures of the teeth, such as gums
and underlying bone.
Posterior means teeth that have flat chewing surfaces, located in the back of the mouth - upper and lower
twenty (20) teeth, including molars, bicuspids (premolars), and wisdom teeth.
Prepayment Fee means the monthly fee paid to Us by Your Organization. The prepayment fee is not the
same as a Co -Payment.
Primary Teeth means the first set of teeth ("baby" teeth).
Prophylaxis means a standard cleaning, the scaling and polishing of teeth to remove plaque and tarter
above the gum fine.
Prosthodontics means the replacement of missing teeth with artificial substitutes. The appliances can be
fixed (bridge or implant) or removable (dentures).
Quadrant means one of the four equal sections into which Your mouth can be divided.
OCERT2011-DHMO-EOC zsC-ss 21
Reasonable and Customary Charge means the least of:
• the amount charged by the Selected General Dentist for a Covered Service;
• the usual amount charged by the Selected General Dentist for dental services which are the
same as, or similar to, the Covered Service; or
the usual amount charged by other Selected General Dentist in the same geographic area for
dental services which are the same as, or similar to, the Covered Service.
Resin -based Composite means tooth -colored (white) fillings.
Selected General Dentist means a SafeGuard contracted dentist who agrees in Writing to provide dental
services under special terms, conditions and financial reimbursement arrangements with SafeGuard,
Selected General Dental Office means a dental office contracted with SafaGuard consisting of dentists who
agree in Writing to provide dental services under special terms, conditions and financial reimbursement
arrangements with SafeGuard.
Service Area means the geographical area in which SafeGuard has a panel of Selected General Dentists
and Specialty Care Dentists who have agreed to provide care to SafeGuard customers, To enroll In the
SafeGuard plan, You and Your dependents (except dependent children) must, reside, live, or work in the
Service Area.
Signed means any symbol or method executed or adopted by a person with the present Intention to
authenticate a record, which Is on or transmitted by paper or electronic media, which is acceptable to Us and
consistent with applicable law.
Specialty Care means services provided by an endodontist, periodontist, pediatric Dentist, oral surgeon, or
orthodontist. These services may be covered at a Co -Payment, or at 75% of the Dentists Reasonable and
Customary Charge.
Specialty Care Dentist means a SafeGuard contracted dentist who agrees in Writing to provide Specialty
Care services under special terms, conditions and financial reimbursement arrangements with SafeGuard.
We, Us and Our mean SafeGuard Health Plans, Inc.
Written or Writing means a record on or transmitted by paper or electronic media which is acceptable to Us
and conslstentwith applicable law.
Year or Yearly means the 12 month period that begins January t.
You and Your mean a person, other than a dependent, who is covered under the group contract for the
dental benefits described in this evidence of coverage.
GCERT2011-DHMO-EOC 250-36 22
MetLife
Our Privacy Notice
We know that you buy our products and services because you trust us, This notice explains how we protect your privacy
and treat your personal information. It applies to current and former customers, 'Personal information" as used here
means anything we know about you personally.
.+ + 9• ,
This privacy notice Is for individuals who apply for or obtain our products and services under an employee benefit plan, or
group Insurance orannuity contract. in this notice, "you" refers to these Individuals.
rI MOW"
We take Important steps to protect your personal Information, We treat It as confidential. We tell our employees to take
care in handling It. We limit access to those who need It to perform their jobs. Our outside service providers must also
protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized
access. We comply with all laws that apply to us.
We typically collect your name, address, age, and other relevant Information. We may also collect information about any
business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They
also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in
other businesses.
We get your personal information mostly from you. We may also use outside sources to help ensure our records are
correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions,
adult relatives, and others. These sources may give us reports or share what they know with others. We don't control the
accuracy of information outside sources give us. If you want to make any changes to information we receive from others
about you, you must contact those sources.
We collect your personal Information to help us decide if you're eligible for our products or services. We may also need it
to verify Identities to help deter fraud, money laundering, or other crimes, How we use this information depends on what
products and services you have or want from us. It also depends on what laws apply to those products and services. For
example, we may also use your Information to:
• administer your products and services
• process claims and other transactions
• perform business research
• confirm or correct your information
• market new products to you
• help us run our business
• comply with applicable laws
We may share your personal Information without your consent if permitted or required bylaw. For example, we may share
your information with businesses hired to carry out services for us, We may also share it with our affiliated or unaffiliated
business partners through joint marketing agreements, In those situations, we share your information to jointly offer you
products and services or have others offer you products and services we endorse or sponsor. Before sharing your
information with any affiliate orjoint marketing partner for their own marketing purposes, however, we will first notify you and
give you an opportunity to opt out.
Other reasons we may share your information include:
• doing what a court, law enforcement, or government agency requires us to do (for example, complying with
search warrants or subpoenas)
• telling another company whatwe know about you If we are selling or merging any part of our business
• giving information to a governmental agency so it can decide if you are eligible for public benefits
CPN -Group -Ann -2015
25C-37
• giving your information to someone with is legal interest in your assets (for example, a creditor with alien on
your account)
• giving your information to your health care provider
• having a peer review organization evaluate your information, if you have health coverage with us
• those listed In our "Using Your Information" section above
We will not share your health information with any other company— even one of our affiliates — for their own
marketing purposes. The Health Insurance Portabllity and Accountability Act ("HIPAA") protects your information
if you request or purchase dental, vision, long-term care and/or medical Insurance from us. HIPAA limits our
ability to use and disclose the information that we obtain as a result of your request or purchase of insurance.
Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or
medical coverage issued to you.
You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLI e.com. Select "Privacy
Policy" at the bottom of the home page. For additional Information about your rights under HIPAA; or to have a
HIPAA Privacy Notice mailed to you, contact us at HIPAAprivacyAmericasUSOmetlife.com, or call us at
telephone number (212) 578-0299.
You may ask us for a copy of the personal information we have about you. Generally, we will provide It as long as it is
reasonably retrievable and within our control. You must make your request In writing listing the account or policy numbers
with the information you want to access. For legal reasons, we may not show you anything we learned as part of a claim
or lawsuit, unless required by law,
If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records.
Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed
information to anyone outside MetLife.
We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us.
When you write, include your name, address, and policy or account number.
Send privacy questions to:
MetLife Privacy Office
P. 0. Box 489
Warwick, RI 02887-9954
PrivacyZmethfe.com
We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide
this privacy notice to you on behalf of these MetLife companies:
Metropolitan Life Insurance Company
MetLife Insurance Company USA
SafeGuard Health Plans, Inc.
CPN -Group -Ann -2015
MetLife Health Plans, Inc.
General American Life Insurance Company
SafeHealth Life Insurance'Company
EXHIBIT 3
SCHEDULE OF BENEFITS
SOB Number SOB Form
1 GCERT20IG-DHMO-SOB
GPNP10-DHMO
Applies to
All Covered Persons --
0041-D
DATE: January 1, 2017
25C-39
Effective Date
January 1, 2017
EXHIBIT 3
MeftifeiSCHEDULE OF BENEFITS
Benefits provided by SafeGuard Health Plans, Inc., a MetLife company
Direct Referral Dental Plan* 0041-D
This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co-
payments associated with each service, There are other factors that Impact how your plan works and those
are Included here In the Exclusions & Limitations. We have also added some dental terminology definitions to
help you better understand your plan - these can be found at the back of this Schedule.
During the course of treatment, your SafeGuard selected general dentist may recommend the services of a
dental specialist.
'Your SafeGuard selected general dentist is responsible for coordinating your dental care, and If necessary,
referring you to a SafeGuard contracted specialist, and will submit all required documentation to SafeGuard
for any necessary referral.
Your and Your
Dependent's
Code Service Co -Payment
Diagnostic Treatment
D0120 Periodic oral evaluation - established patient $0
D0140
Limited oral evaluation - problem focused
$0
D0145
Oral evaluation for a patient under three years of age and counseling with
$0
primary caregiver
00150
Comprehensive oral evaluation - new or established patient
$0
D0171
Re-evaluation — past -operative office visit
$0
D0180
Comprehensive periodontal evaluation - new or established patient
$0
Office visit — per visit (including all fees for sterilization and/or Infection control
$0
Radiographs / Diagnostic Imaging (X-rays)
$0
00210
Intraoral — complete series of radiographic Images
$0
D0220
Intraoral — periapical first radiographic image
$0
D0230
Intraoral— perlapical each additional radiographic image
$0
D0240
Intraoral— occlusal radiographic Image
$0
D0250
Extraoral —first radiographic Image
$0
D0200
Extraoral — each additional radiographic image
$0
D0270
Hawing—single radiographic image
$0
D0272
Bitewings — two radiographic images
$0
D0273
Bitewings — three radiographic Images
$0
D0274
Bitewings —four radiographic Images
$0
D0330
Panoramic radiographic Image
$0
D0350
2D oral/facial photographic image obtained intra -orally or extra -orally
$0
Tests and Examinations
D0460
Pulp vitality tests
$0
D0470
Diagnostic casts
$0
0041 -D -SOB
2SC-40
1
01115
SCHEDULE OF BENEFITS (Continued)
0041 -13 -SOB
25C-41
F
The use of noble or high noble for any procedure will include additional lab
Your and Your
fees.
Dependent's
Code
Service
Co -Payment
D2710
Preventive Services
$0
D2712
Procedures Identified with an asterisk (�) are limited to twice a year, unless
$0
D2740
medically necessary.
$0
D1110
Prophylaxis — adult"
$0
01120
Prophylaxis — child"
$0
D1206
Topical application of fluoride varnish"
$0
D1208
Topical application of fluoride — excluding varnish
$0
D1330
Oral hygiene Instructions
$0
D1351
Sealant — per tooth
$0
D1510
Space maintalner— fixed — unilateral
$0
D1615
Space maintainer — fixed — bilateral
$0
D1520
Space malntalner— removable —unilateral
$0
D1525
Space maintainer — removable — bilateral
$0
D1850
Re -cement or re -bond space maintainer
$0
D1555
Removal of fixed space maintainer
$0
Restorative Treatment
D2140
Amalgam — one surface, primary or permanent
$0
D2150
Amalgam — two surfaces, primary or permanent
$0
D2160
Amalgam — three surfaces, primary or permanent
$0
D2161
Amalgam —four or more surfaces, primary or permanent
$0
D2330
Resin -based composite—one surface, anterior
$0
D2331
Resin -based composite — two surfaces, anterior
$0
D2332
Resin -based composite — three surfaces, anterior
$0
D2335
Resin -based composite — four or more surfaces or involving incisal angle
$0
(anterior)
D2390
Resin -based composite crown, anterior
$0
Crowns
0041 -13 -SOB
25C-41
F
The use of noble or high noble for any procedure will include additional lab
fees.
$75 fee per crown unit above co -pay for porcelain on molars.
D2710
Crown — resin -based composite (indirect)
$0
D2712
Crown —a/a resin -based composite (Indirect)
$0
D2740
Crown — porcelaintceramic substrate
$0
D2750
Crown — porcelain fused to high noble metal
$0
D2751
Crown—porcelain fused to predominantly base metal
$0
D2752
Crown—porcelain fused to noble metal
$0
D2780
Crown-'/ cast high noble metal
$0
D2781
Crown -3/ cast predominantly base metal
$0
D2782
Crown —'/a cast noble metdl
$0
D2790
Crown —full cast high noble metal
$0
D2791
Crown — full cast predominantly base metal
$0
D2792
Crown — full cast noble metal
$0
0041 -13 -SOB
25C-41
F
SCHEDULE OF BENEFITS (Continued)
Code Service
Your and Your
Dependent's
Co -Payment
02794
Crown—titanium
$0
D2910
Re -cement or re -bond inlay, onlay, veneer or partial coverage restoration
$0
D2915
Re -cement or re -bond Indirectly fabricated or prefabricated post and cora
$0
D2920
Re -cement or re -bond crown
$0
D2930
Prefabricated stainless steel crown — primary tooth
$0
D2931
Prefabricated stainless steel crown — permanent tooth
$0
D2940
Protective restoration
$0
D2950
Core buildup, Including any pins when required
$0
D2951
Pin retention — per tooth, in addition to restoration
$0
D2952
Post and core in addition to crown, Indirectly fabricated
$0
D2953
Each additional Indirectly fabricated post—same tooth
$0
D2954
Prefabricated post and core In addition to crown
$0
D2970
Temporary crown (fractured tooth)
$0
Endodontics
All procedures exclude final restoration.
$0
D3110
Pulp cap — direct (excluding final restoration)
$0
D3120
Pulpcap--indirect(excludingfinalrestoration)
$0
D3220
Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to
$0
the dentinocemental Junction and application of medicament
D3310
Endodontic therapy, anterior tooth (excluding final restoration)
$0
D3320
Endodontlo therapy, bicuspid tooth (excluding final restoration)
$0
D3330
Endodontic therapy, molar tooth (excluding final restoration)
$0
D3332
Incomplete endodontic therapy; Inoperable, unrestorable or fractured tooth
$0
D3346
Retreatment of previous root canal therapy -- anterior
$0
03347
Retreatment of previous root canal therapy — bicuspid
$0
03348
Retreatment of previous root canal therapy — molar
$0
D3351
Apexifloatlonlrecalcificatlon — initial visit (apical closure / calcific repair of
$0
perforations, root resorption, etc.)
D3410
Apicoectomy—anterior
$0
D3421
Apicoectomy — bicuspid (first root)
$0
D3426
Apicoectomy — molar (first root)
$0
D3426
Apicoeotomy (each additional root)
$0
D3430
Retrograde filling — per root
$0
Periodontics
D4210
Gingivectomy or gingivoplasty—four or more contiguous teeth or tooth
$0
bounded spaces per quadrant
04211
Gingivectomy or gingivoplasty — one to three contiguous teeth or tooth bounded
$0
spaces per quadrant
D4240
Gingival flap procedure, including root planing — four or more contiguous teeth
$0
or tooth bounded spaces per quadrant
D4241
Gingival flap procedure, including root planing — one to three contiguous teeth
$0
or tooth bounded spaces per quadrant
04260
Osseous surgery (including elevation of a full thickness flap and closure) —four
$0
or more contiguous teeth or tooth bounded spaces per quadrant
0041 -0 -SOB
3
25C-42
SCHEDULE OF BENEFITS (Continued)
Your and Your
Dependent's
D4261
Osseous surgery (Including elevation of a full thickness flap and closure) — one
$0
to three contiguous teeth or tooth bounded spaces per quadrant
D4341
Periodontal scaling and root planing —four or more tooth per quadrant
$0
D4342
Periodontal scaling and root planing —one to three teeth per quadrant
$0
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis
$0
D4910
Periodontal maintenance
$0
Removable Prosthodontics
•
Replacement limit I every 3 years.
•
Denture relines. Twice in one year
•
Includes up to 3 adjustments within 6 months of delivery.
05110
Complete denture—maxillary
$0
D5120
Complete denture — mandibular
$0
D5130
Immediate denture — maxillary
$0
D5140
Immediate denture — mandibular
$0
D5211
Maxillary partial denture -- resin base (Including any conventional clasps, rests
$0
and teeth)
D5212
Mandibular partial denture— resin base (including any conventional clasps,
$0
rests and teeth)
D5213
Maxillary partial denture— cast metal framework with resin denture bases
$0
(including any conventional clasps, rests and teeth)
D5214
Mandibular partial denture —cast metal framework with resin denture bases
$0
(including any conventional clasps, rests and teeth
D5410
Adjust complete denture—maxillary
$0
D5411
Adjust complete denture — mandibular
$0
D5421
Adjust partial denture — maxillary
$0
D5422
Adjust partial denture — mandibular
$0
D5510
Repair broken complete denture base
$0
D5520
Replace missing or broken teeth—complete denture (each tooth)
$0
D5610
Repair resin denture base
$0
D5620
Repair cast framework
$0
D5630
Repair or replace broken clasp
$0
D5640
Replace broken teeth — per tooth
$0
D565D
Add tooth to existing partial denture
$0
D6660
Add clasp to existing partial denture
$0
D5710
Rebase complete maxillary denture
$0
D5711
Rebase complete mandibular denture
$0
05720
Rebase maxillary partial denture
$0
D5721
Rebase mandibular partial denture
$0
D5730
Reline complete maxillary denture (chairside)
$0
D5731
Reline complete mandibular denture (chalrside)
$0
D5740
Reline maxillary partial denture (chairside)
$0
D5741
Reline mandibular partial denture (chairside)
$0
D5750
Reline complete maxillary denture (laboratory)
$0
0041 -D -SOB
25C-43.
4
SCHEDULE OF BENEFITS (Continued)
0041 -D -SOB
26C-44
5
Your and Your
Dependent's
Code
Service
Co -Payment
D5751
Reline complete mandibular denture (laboratory)
$0
D5760
Reline maxillary partial denture (laboratory)
$0
D5761
Reline mandibular partial denture (laboratory)
$0
D5820
Interim partial denture (maxillary)
$0
D5821
Interim partial denture (mandibular)
$0
D5860
Tissue conditioning, maxillary
$0
D5851
Tissue conditioning, mandibular
$0
CrownslFixed Bridges - Per Unit
The use of noble or high noble fcr any procedure will Include additional lab
fees,
$75 fee per crown/bridge unit above co -pay for porcelain on molars,
D6206
Pontic— Indirect resin based composite
$0
06210
Pontic—cast high noble metal
$0
D6211
Pontic — cast predominantly bass metal
$0
D6212
Pontic—cast noble metal
$0
D6214
Pontic — titanium
$0
D6240
Pontie — porcelain fused to high noble metal
$0
D6241
Pontic— porcelain fused to predominantly base metal
$0
06242
Pontic — porcelain fused to noble metal
$0
D6250
Pontic — resin with high noble metal
$0
D6251
Pontic — resin with predominantly base metal
$0
D6252
Pontic — resin with noble metal
$0
D5710
Crown — Indirect resin based composite
$0
06720
Crown — resin with high noble metal
$0
D6721
Crown— resin with predominantly base metal
$0
D6722
Crown—resin with noble metal
$0
D6760
Crown— porcelain fused to high noble metal
$0
D6751
Crown — porcelain fused to predominantly base metal
$0
D6762
Crown — porcelain fused to noble metal
$0
D6780
Crown - % cast high noble metal
$0
D6781
Crown —3/<castpredominantly bass metal
$0
D6782
Crown — % cast noble metal
$0
D6790
Crown —full cast high noble metal
$0
D6791
Crown—full cast predominantly base metal
$0
D6792
Crown —full cast noble metal
$0
D6794
Crown—titanium
$0
D6930
Re -cement or re -bond fixed partial denture
$0
Oral Surgery
Includes routine post operative visits/treatment.
Surgical removal of impacted teeth - (not covered unless pathology [disease]
exists).
0041 -D -SOB
26C-44
5
SCHEDULE OF BENEFITS (Continued)
0041 -D -SOB
25C-45
Your and Your
Dependent's
Code
Service
Co -Payment
Surgical removal of wisdom tooth/third molar for orthodontic reasons only is not
covered.
D7140
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
$0
D7210
Surgical removal of erupted tooth requiring removal of bone and/or sectioning
$0
of tooth and including elevation of mucoperiosteal flap if indicated
D7220
Removal of Impacted tooth — soft tissue
$0
D7230
Removal of Impacted tooth — partially bony
$0
D7240
Removal of impacted tooth — completely bony
$0
D7250
Surgical removal of residual tooth roots (cutting procedure)
$0
07285
Inclsional biopsy of oral tissue— hard (bone, tooth)
$0
D728e
Incisional biopsy of oral tissue — soft
$0
67310
Alveoloplasty in conjunction with extractions — four or more teeth or tooth
$0
spaces, per quadrant
D7311
Alveoloplasty in conjunction with extractions — one to three teeth or tooth
$0
spaces, per quadrant
D7320
Alvaoloplasty not in conjunction with extractions — four or more teeth or tooth
$0
spaces, per quadrant
D7321
Alveoloplasty not in conjunction with extractions — one to three teeth or tooth
$0
spaces, per quadrant
07960
Frenulectomy — aka frenectomy or frenotomy— separate procedure not
incidental to another procedure
$0
D7903
Frenuloplasty
$0
Orthodontics
D8020
' Limited orthodontic treatment of the transitional dentition
(up to 24 months)
$500
D8030
Limited orthodontic treatment of the adolescent dentition
(up to 24 months)
$500
D8040
Limited orthodontic treatment of the adult dentition (up to 24 months)
$500
D8070
Comprehensive orthodontic treatment of the transitional dentition (full
treatment case up to 24 months - Including fixed/removable appliances)
$1,000
D8080
Comprehensive orthodontic treatment of the adolescent dentition (full
treatment case up to 24 months - including fixed/removable appliances)
$1,000
D8090
Comprehensive orthodontic treatment of the adult dentition (full
treatment case up to 24 months - Including fixed/removable appliances)
$1,000
D8660
Pre -orthodontic treatment examination to monitor growth and development
$26
D86BO
Orthodontic retention (removal of appliances, construction and placement of
retainer(s))
$260
D8693
Re -cement or re -bond fixed retainers
$0
Adjunctive General Services
D9110
Palliative (emergency) treatment of dental pain — minor procedure
$0
D9120
Fixed partial denture sectioning
$0
D9215
local anesthesia In conjunction with operative or surgical procedures
$0
D9219
Evaluation for deep sedation or general anesthesia
$0
D9310
Consultation — diagnostic service provided by dentist or physician other than
requesting dentist or physician
$0
0041 -D -SOB
25C-45
SCHEDULE OF BENEFITS (Continued)
Your and Your
Dependent's
Code Service Co -Payment
D9430 Office visit for observation (during regularly scheduled hours) — no other
services performed $0
09440 Office visit— after regularly scheduled hours $0
09952 Occlusal adjustment — complete
D9986 Missed appointment
(less than 24 -hr notice)
D9987 Cancelled appointment
(if less than 24 -hr notice, see D9986)
0041 -D -SOB
Current Dental Terminology 0 American Dental Association
25C-46
$0
Not to exceed
$25
$0
Dental Terminology Definitions
These definitions are designed to give you a "layman's understanding" of some dental terminology in
order for you to better understand your plan; they are not full descriptions,
Amalgam:
A silver filling
Anterior:
Teeth that are in the front of the mouth
Bicuspid:
Most people have eight bicuspid teeth; they are located Immedfately
preceding the molar teeth with two In each quadrant of the mouth.
Bridge:
A replacement for one or more missing teeth that is permanently attached
to the teeth adjacent to the empty space(s),
Crown:
A covering created to place over a tooth to strengthen and/or replace
tooth structure. A crown can be made of different materials (noble, high
noble), base metal, porcelain or porcelain and metal,
Endodontics:
Procedures that treat the nerve or the pulp of the tooth due to Injury or
infection,
Oral Surgery:
Surgery to remove teeth, reshape portions of the bone in the mouth, or
biopsy suspect areas of the mouth.
Orthodontics:
Braces and other procedures to straighten the teeth.
Periodontics:
Procedures related to treatment of the supporting structures of the
teeth (gums, underlying bone).
Posterior:
Teeth that set towards the back of the mouth, including molars and
bicuspids (premolars).
Primary Teeth:
The first set of teeth ("baby" teeth).
Prophylaxis:
Scaling and polishing of teeth by removal of the plaque above the gum
line.
Prosthodontics; The restoration of natural and/or the replacement of missing teeth
with arllflcial substitutes.
Quadrant; One of the four equal sections Into which your mouth can be divided (some
procedures like perlodontics are done in quadrants).
Resin -based
Composite: Tooth -colored (white) fillings
0041 -D -SOB
25C-47
Exclusions and Limitations
Exclusions
1. Services performed by a general dentist or dentist whose practice is limited to providing Specialty
Care, not contracted with SafeGuard without prior approval by SafeGuard, (except for out of area
emergency services).
2. Any dental services, or appliances which are determined to be not reasonable and/or necessary
for maintaining or improving the member's dental health, as determined by the SafaGuard
Selected General Dentist.
3. Any procedures not specifically listed as a covered benefit in the Schedule of Benefits.
4. Dental procedures or services performed solely for cosmetic purposes or solely for appearance.
6. Orthognathic surgery.
6. Any inpatlentfoutpatient hospital charges of any kind including dentist and/or physician charges,
prescriptions or medications.
7. Replacement of dentures, crowns, appliances or bridgework that have been lost, stolen, or
damaged due to abuse, misuse,or neglect.
8. Treatment of malignancies, cysts, or neoplasms.
9. Procedures, appliances, or restorations whose main purpose Is to change the vertical dimension
of occlusion, correct congenital, developmental, or medically Induced dental disorders Including,
but not limited to treatment of myofunctional, myoskeletal, or temporomandlbular Joint disorders
unless otherwise specified as an orthodontic benefit on the Schedule of Benefits,
10. Dental implants and services associated with the placement of implants, prosthodontics
restoration of dental implants, and specialized implant maintenance services,
11. Precision attachments.
12. Dental procedures initiated prior to the member's eligibility under this Plan or started after the
member's termination from the Plan.
13. Dental services provided for or paid by a federal or state government agency or authority, political
subdivision, or other public program other then Medicaid or Medicare.
14. Dental services required while serving In the Armed Forces of any country or international
authority or relating to a declared or undeclared war or acta of war.
16. Services considered unnecessary or experimental in nature.
16. Dental procedures or appliances for minor tooth guidance or for the control of harmful habits such
as thumb sucking and tongue thrusting.
17. Any dental procedure or treatment unable to be performed in the dental office due to the general
health or physical limitations of the member including, but not limited to physical or emotional
resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics.
0041 -D -SOB
25C-48
EL's 2.15
Exclusions and Limitations
Limitations
1. Cleanings (prophylaxis) and fluoride treatments are limited to twice a year unless medically
necessary.
2. An additional charge will be applied for any procedure using noble or high noble metal.
3. Full -mouth X-rays: Once initially and thereafter when diagnostically necessary,
4. Periodontal maintenance procedures are a covered benefit only when listed as a covered service
on your plan's Schedule ofBensflts. If covered, periodontal maintenance procedures mustfollow
active periodontal therapy, and are limited to 21n a 12 month period.
5. Dentures (full or partial): Replacement only after three (3) years have elapsed following any prior
provision of such dentures under a SafeGuard Benefit Plan, Replacements will be a benefit only if
the existing denture Is unsatisfactory and can not be made satisfactory as determined by the
SafeGuard Selected General dentist.
6. Denture relines: Twice in one year
7. Sealants are a covered benefit only when they are listed as a covered service on your plan's
Schedule of Benefits. If covered, the plan benefit applies io primary and permanent molar teeth,
within four (4) years of eruption.
8. There is a $75 co -payment per crown/bridge unit In addition to regular co -payments for porcelain
on molars.
9. Surgical removal of wisdom teeth/third molar for orthodontic reasons only is not a covered
benefit.
10. Delivery of removable prosthodontics includes up to three (3) adjustments within six (6) months of
delivery date of service.
11. Surgical removal of impacted teeth is not a covered benefit unless pathology [disease] exists.
12. The co -payments listed for endodontic procedures do not Include the cost of final restoration.
13. General anesthesia Is a covered benefit only when it is listed as a covered service on your plan's
Schedule of Benefits, and when It Is administered by the treating dentist, In conjunction with oral
and periodontal surgical procedures,
Orthodontic Exclusions & Limitations
1. Orthodontic treatment must be provided by a SafeGuard Selected General Dentist or contracted
dentist whose practice is limited to providing Specialty Care in order for the co -payments listed In
the Schedule of BeneNts to apply,
2. Plan benefits shall cover twenty-four (24) months of usual and customary orthodontic treatment
and an additional twenty-four (24) months of retention. Treatment extending beyond such time
periods will be subject to a per -office -visit charge of $25 dollars.
3. The following are not Included as orthodontic benefits:
A. Repair or replacement of lost or broken appliances;
B. Retreatment of orthodontic cases;
C. Treatment In progress at Inception of eligibility;
0041 -D-SOB
Eva 2.15
Exclusions and Limitations
D. Interceptive or phase I orthodontics;
E. Changes in treatment necessitated by an accident;
F. Treatment Involving:
1) Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia
2) Hormonal imbalances or other factors affecting growth or developmental abnormalities;
3) Treatment related to temporomandibularjoint disorders;
4) Lingually placed direct bonded appliances and arch wires Cinvisible braces"); and
5) Functional appliances that are used in conjunction with fixed appliances.
G. Diagnostic records:
1) Cephalometric x-rays and other x-rays;
2) Diagnostic tracings of cephalometric x-rays;
3) Photographs; and
4) Study models.
4. The retention phase of treatment shall Include the construction, placement, and adjustment of
retainers,
5. Should a member or client terminate from the Plan for any reason and at that time be receiving
orthodontic treatment, the Member and not SafeGuard shall be responsible for payment of the
balance due for any orthodontic treatment performed after termination. The member's payment
shall be increased by an additional $2,050 above the membe's co -payment and excluding any
charges for diagnostic records, shall be prorated over the number of months to completion of
active treatment, and be payable on such terms and conditions as are arranged between the
Member and the orthodontist.
6. The retention phase of treatment, if required, shall include the construction, placement and
adjustment of retainers, the maximum cost of which shall not exceed $250.00.
7. If a member does not require treatment or chooses not to start treatment after the participating
SafeGuard orthodontist has completed a diagnosis and consultation, the Member will be charged
a consultation fee of $25.00 in addition to the fees for such diagnostic records.
0041 -0 -SOB
25C-50
EL's 2.79
LANGUAGE ASSISTANCE
As a SafeGuard member you have a right to free language assistance services, Including interpretation
and translation services. SafeGuard collects and maintains your language preferences, race, and
ethnicity so thatwe can communicate more effectively with our members. If you require language
assistance or would like to inform SafoGuard of your preferred language, please contact SafeGuard at
(800) 880-1800,
Como miembro de SafeGuard usted tier derecho a recibir servicios gratuitos de aslstancia an Idlomas.
Esto Incluye servicios de Interpretacl5n y traduccldn. SafeGuard recaba Is Informacldn sobre sus
preferencias de idioma, raze, y etnia de manera qua nos podamos comunicar eficazmente con nuestros
afillados. Si necesita aslstencia an su Idioms o qulere informarle a SafeGuard sabre su idioma de
preferencla, comuniquese con SafeGuard al (800) 880-1800.
f' AS8fGGUafdft*,R, rW#aQX409 a $AWardMIM94F
f9MO, 120M AIRI RMSafeGuard, afMa WjA;WAMSafeQUatdM 10
A(800) 88o"Wo
25C-51
COTC PROCESSING FORM
Agreements / Amendments / Deeds".'
TO: CLERK OF THE COUNCIL OFFICE
FROM: DEPT.: Personnel
PROJECT MANAGER: Carrie Hanes
MAIL STOP:
AGREEMENT NUMBER (if amendment): A / N --Z�ce) \ q 0-1— `>
AMENDMENT NUMBER (if applicable): ❑ 1ST ❑ 2ND ❑ 3RD ❑
NAME OF CONSULTANT/ PARTY: Met Life Dental
24
EXT.: 6967
AMOUNT: ❑ * OVER $25,000 — (A) ❑ *UP TO $25,000 - (N) Note: If your agreement with a vendor exceeds $25,000
within a Fiscal Year, then you will need to obtain Council
Approval.
❑ 1) NOT approved by council.
0 2) Approved by council.
COUNCIL APPROVAL DATE: 2/6/18 ITEM #:
25C
TERM OF AGREEMENT- EFFECTIVE DATE: January 1, 2018 TERMINATION DATE:
SIGNATURES REQUIRED: ❑ VENDOR 0 AGENCY
❑ CITY ATTORNEY ❑ OTHER
December 31, 2019
(INSURANCE APPROVAL REQUIRED BY CAO PRIOR TO SUBMITTING TO COTC)
INSURANCE REQUIRED: ❑✓ YES ❑ NO (Provide City Attorney Office approval)
❑ AUTO ❑ CGL (Commercial General Liability)
❑ PROFESSIONAL LIABILITY ❑ WORKERS COMPENSATION
COMMENTS:
FOR CLERK OFFICE USE ONLY:
❑ PROCESS ❑ DO NOT PROCESS
❑ Needs Council Approval
❑ Missing Signatures
❑ Other
* Charter amendment effective December 21, 2006 for City Manager contract authority increase; NS -2717
I:LAgreementsVorm -AGREEMENT PROCESSING FORM_canary.doc
Revised: 1/17/2012