California Dental
Network HMO Dental Plans
Extension of
eligibility may be made up to the age of 23 years for unmarried children
who are principally dependent upon the subscriber and are registered
students in regular, full-time attendance at an accredited school,
college, or university (subscriber will be required to submit evidence of
full-time status). There are no deductibles and no yearly limits on
services, and there are no claim forms to fill out. The dentists must meet
the Plan's standard of quality and service. All have agreed to provide
dental care at a low cost available only to its members. There is no
waiting period for your dental services to begin, pre-existing dental
conditions are covered. A reminder your application must be received by
the company on or before the last day of the month prior to the following
month's coverage effective date.
An Enrollment Application is a
request for coverage, which, if approved by California Dental Network,
becomes the enrollment form used to issue an identification card and
Combined Evidence of Coverage and Disclosure Form. All benefits,
limitations and exclusions are stated in full in the Combined Evidence
of Coverage and Disclosure Form which is provided when coverage
becomes effective. Members will have 30 days from receipt of the
Combined Evidence of Coverage and Disclosure Form to cancel their
enrollment and receive a full refund of their premiums if they have
not utilized the Plan. You may obtain a copy of the Combined Evidence
of Coverage and Disclosure Form from their Corporate Office before you
enroll.
Limitations (1) Prophylaxis (cleaning) is limited to once every six
months. (2) Fluoride treatment is covered once every 12 months for
Members up to age 14. (3) Bitewing x-rays are limited to one series of
four films every 12 months. (4) Full mouth x-rays are limited to once
every 24 months. (5) Sealants are covered for Members up to the age of
14 and are limited to permanent first and second molars. (6)
Periodontal treatments (subgingival curettage and root planing) are
limited to one treatment per quadrant in any 12-month period. (7)
Fixed bridgework will be covered only when a partial cannot
satisfactorily restore the case.(8) Replacement of partial dentures is
limited to once every five years. (9) Full upper and/or lower dentures
are not to exceed one each in any five-year period. (10) Denture
relines are limited to one per arch in any 12-month period.
Exclusions (1) General anesthesia,
analgesia (nitrous oxide), intravenous sedation, or the services of an
anesthesiologist. (2) Treatment of fractures or dislocations;
congenital malformations; malignancies, cysts, or neoplasms; or
Temporomandibular Joint Syndrome (TMJ). (3) Extractions or x-rays for
orthodontic purposes. (4) Prescription drugs and over the counter
drugs. (5) Any services involving implants or experimental procedures.
(6) Any procedures performed for cosmetic, elective or aesthetic
purposes. (7) Any procedure to replace or stabilize tooth structure
lost by attrition, abrasion, erosion or grinding.
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Not all general dentists are
capable of performing each of the services listed herein and,
based upon the Member’s condition, certain procedures may not be
within the scope of practice or ability of a general dentist. In
such cases, the general dentist will refer the Member to a
California Dental Network participating dental specialist, who
will give the Member a 30% discount from their regular fees
during the first year of enrollment, and a 50% discount
thereafter, for up to $1,000 in services per year. The ratio of
premium costs to health services paid, for plan contracts with
individuals and groups of 25 or fewer members, during the
preceding fiscal year was 0%. * UCR means the dentist’s or
specialist’s Usual, Customary & Reasonable fees. # Member is
responsible for the payment shown plus the actual lab cost of
gold. Orthodontists may charge Members additional fees for costs
of cases over 24 months, based on the differences in UCR fees
for the needed treatment periods less the UCR fees for a
24-month treatment period. |
The California Department of Managed
Health Care is responsible for regulating health care service plans.
If you have a grievance against your Health Plan, you should first
telephone your Health Plan at 1-714-479-0777 or toll-free
1-877-4-DENTAL and use your Health Plan’s grievance process before
contacting the Department. Utilizing this grievance procedure does not
prohibit any potential legal rights or remedies that may be available
to you. If you need help with a grievance involving an emergency, a
grievance that has not been satisfactorily resolved by your Health
Plan, or a grievance that has remained unresolved for more than 30
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
(1-877-688-9891) for the hearing and speech impaired. The Department’s
Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR
application forms and instructions online.
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