Reviewing the California New Dental Choice Discount Plan for the Los Angeles, Orange, and Ventura counties. This dental plan offers individual and family dental services. A family includes individual, spouse, and legal dependents (including children up to age 26). Unlike tradition dental insurance plans there are no deductibles and no yearly limits on services, and there are no claim forms to fill out. Your savings are in place when you visit network dentist. You just show up for your dental appointment and make your payment – what could be easier?
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 and best of all, the dental plan services start once your application and payment is received and processed by the dental plan company. Review the sample schedule below and see how easy it is for you or your entire family to enjoy these quality dental services.
Individual and Family Combined Membership: Agreement and Description of Services and Disclosure Form
The following terms and conditions of this Individual and Family Membership Agreement and Description of Services and Disclosure Form (the Agreement”) govern New Dental Choice, offered by First Dental Health, (“FDH”) and the Services available thereunder. Subscribers and their eligible dependents are subject to all of the provisions, definitions, limitations and conditions of this Agreement. The Plan’s address from which it conducts its business is 7220 Trade Street, Suite 350, San Diego, California 92121. All persons subscribing to The Plan should read the terms of this Agreement carefully and communicate any questions that may arise to a Plan representative available by telephone Monday-Friday 8 am to 5 pm PST at 1-888-NDC-ENROLL (1-888-632-3676). By accepting enrollment in The Plan, Subscriber is agreeing to the terms of this Agreement.
Please read the following information so you will know from whom or what group of dentists your dental care discounts may be obtained.
THIS IS NOT AN INSURANCE POLICY.
ACT means the Knox-Keene Health Care Service Plan Act of 1975, as amended. Plan is subject to the Act.
DENTAL CARE SERVICES means those dental care services eligible for discounted fees under this Agreement.
DEPARTMENT means the California Department of Managed Health Care.
DESCRIPTION OF SERVICES means this Combined Membership Agreement and Description of Services and Disclosure Form issued to a Subscriber or Enrollee setting forth the Services to which the Subscriber or Enrollee is entitled and the conditions and procedures for obtaining discounted Dental Care Services.
DISCOUNT DENTAL FEE PLAN means an entity that, in exchange for fees, dues, charges or other considerations, provides access to its members to providers of dental care services and the right to receive discounts on dental care services from those providers. Such a Plan contracts with providers, provider networks or other Discount Fee Plan organizations to offer discounted fees for dental care services and other healthcare services and determines the membership charge to Discount Dental Fee Plan members.
ELIGIBLE DEPENDENTS means the lawful spouse of the Subscriber (unless legally separated), a dependent parent (provided proof of dependency is furnished to the Plan by the Subscriber at the time of enrollment), or the unmarried children (including step-children, adopted and foster children who are dependent on the Subscriber for support and maintenance) of the Subscriber, from and after birth, until their 19th birthday (or 24th if a full-time student). At attainment of age nineteen (19), coverage as a dependent shall be extended if the child is and continues to be both (1) incapable of selfsustaining employment by reason of diminished mental capacity or physical handicap and (2) chiefly dependent upon the Subscriber for support and maintenance provided proof of such incapacity and dependency is furnished to the Plan by the Subscriber within thirty-one (31) days of the Plan’s request for such proof.
ENROLLEE means a person who is enrolled in Plan.
MEMBER means any eligible Subscriber and his or her eligible dependent(s) for whom the appropriate Membership Fee has been paid.
MEMBERSHIP FEE means those amounts payable monthly or annually as set forth herein as consideration for membership in Plan and access to the discounts provided.
NON-PARTICIPATING PROVIDER means general dentists or specialist dentists who are not contracted with the Plan.
PARTICIPATING PROVIDER means general dentists or specialist dentists who are contracted with the Plan to provide discounts for Dental Care Services to eligible Members.
PLAN means New Dental Choice, a program of First Dental Health, Inc.
PLAN CONTRACT means a contract, such as this Agreement, between the Plan and its Subscribers or a person or entity contracting on behalf of Members pursuant to which access to discounted dental fees from Participating Providers is provided.
SERVICE AREA means a geographical area designated by Plan within which it provides access to discounted dental fees. The Service Areas are described in Attachment “B” to this Agreement. Services are not available outside the Service Areas.
SERVICES mean the discounted fees for Dental Care Services from Participating Providers available to Members as determined by the Plan.
SERVICES IN PROGRESS means Dental Care Services provided by a Participating Provider requiring more than one (1) day to complete, or of such a nature that a Member would not reasonably contract to have the first of the services without assurance that each of the later services would be performed in sequence according to the agreed-upon schedule or on dates reasonably close to the scheduled dates, and the first of which Dental Care Services have been performed on or before the date on which Plan Membership terminates. “Services in Progress” do not include dental care services, whether directly or indirectly related thereto, begun before the effective date of Member’s Plan membership.
SUBSCRIBER means the individual who has paid a Membership Fee.
2. DESCRIPTION OF THE PLAN:
The Plan is a Discount Dental Fee Plan. Each Plan Member is entitled to receive discounts on specified Dental Care Services from a Participating Provider. Members are entitled to receive predetermined discounts for certain listed Dental Care Services from Participating Providers and to receive a 15% discount off the Participating Provider’s normal retail prices for all other unlisted Dental Care Services. The vast majority of dental fees are contracted for at levels significantly reduced from the dentist’s usual fees. Fees for unlisted Dental Care Services are contracted for at a 15% discount off of the Participating Providers usual and customary fee for such Services. Fees for discounted Dental Care Services vary by region. The Plan reviews the terms and conditions regarding Services, Dental Care Services eligible for discounts, and the discounted fees on an annual basis and each is subject to change, modification, or substitution by Plan each year on January 1. Plan will deliver to the Member a notice in writing at least 30 days prior to implementing any such changes. The Plan will also deliver to the Member a notice in writing indicating any changes in premium rates, discounted fees or services at least 30 days prior to the contract renewal effective date. If a Member wishes to confirm the discounted fee for a particular Dental Care Service, or would like to know the business hours for a Participating Provider, he/she should telephone a Plan representative at the toll-free number 1-888-NDC-ENROLL (1-888-632-3676), located on the Membership card, or go to the Plan’s website at www.NewDentalChoice.com. Plan may at some future time offer discount fee programs for other, non-dental care services, such as vision and prescription drugs. If Plan decides to offer such other discount fee programs, it will do so by means of a supplementary rider to this Agreement. Individual will be notified of the opportunity and procedures to subscribe to such other discount fee plans.
3. DISCOUNTED FEES:
The Dental Care Services listed in Attachment “A” comprise a partial list of over 330 procedures discounted to fixed fees which represent the vast majority of the dental care services typically required by patients. All fees for procedures listed herein are the maximum fees for which a Member shall be responsible. In the event a Participating Provider’s usual and customary fees are lower than the Plan’s discounted fees, the Member shall only be liable for the lower of the two fees.
4. OTHER CHARGES:
The vast majority of dental care fees are contracted for at levels significantly reduced from the dentist’s usual fees. Fees for unlisted Dental Care Services are contracted for at a 15% discount off of the Participating Provider’s usual and customary fee for such Services.
5. PRINCIPAL EXCLUSIONS AND LIMITATIONS:
Dental Care Services must be received from a Participating Provider. Dental Care Services or expenses incurred or in connection with any dental procedures started prior to the Member’s effective date under this Agreement or after termination of the Member’s Membership are excluded. (Examples: teeth prepared for crowns, root canal treatment in progress, orthodontic treatment in progress.)
6. MEMBERSHIP FEES:
Membership Fees applicable to this Agreement, including monthly and annual Membership Fees for Individuals and for Families, are contained in Attachment “C” to this Agreement, which Attachment is incorporated herein by this reference.
7. EFFECTIVE DATE OF COVERAGE:
All persons who have submitted the required enrollment information to the Plan and have either paid or had paid on their behalf the appropriate Membership Fee shall be considered Members and eligible for discounts upon receipt of their Member I.D. card. Renewal dates for Members enrolling and paying annually will begin on the anniversary date of initial membership.
8. IDENTIFICATION OF MEMBER:
The Plan issues each Subscriber two (2) I.D. cards. One must be presented at the time Dental Care Services are obtained at a Participating Provider. The Member must pay the Provider at the time that Dental Care Services are received unless otherwise agreed upon between Provider and Member. The Member is not required to file any claims.
9. CHOICE OF DENTISTS AND PROVIDERS; IMPACT UPON MEMBER’S LIABILITY FOR PAYMENT:
a) Each Member must use a Participating Provider in order to receive services. The Plan does not assign Members to Participating Providers and Member is free to select and receive Dental Care Services from any Participating Provider. Participating Providers for Member’s geographic area may be located using Plan’s website or by telephoning the Plan at 1-888-NDC-ENROLL (1-888-632-3676). The Plan maintains an extensive network of general dentists and specialists. In most geographic areas there are specialist dentists in reasonable proximity to where Members reside. In some more rural areas, however, some specialties may not be available. Should the need arise, Members should call the Plan or consult the Plan’s website to determine where a particular specialty may be found in the Member’s area.
b) The Plan does not require notification from the Member if Member wants to change from one Participating Provider to a different Participating Provider. These rules of selection and freedom to change Participating Providers apply both to general dentists and to specialists. Member shall be solely responsible for any charges for any dental treatment received from a Non-Participating Provider under any circumstances or for any reason.
c) Unless the Member or the Plan requests otherwise, a Participating Provider withdrawing or being terminated from the Plan is obligated to provide, following the date of his or her termination from the Plan, Dental Care Services to a Member in the course of commenced but uncompleted treatment by the Provider on the date of such withdrawal or termination from the Plan at the discounted fees to which the Member is entitled under this Agreement until the course of treatment has been completed.
d) Should the Plan cease to be in business, the Participating Provider is obligated to continue to provide Dental Care Services to Members at the discounted fees to which the Member is entitled under this Agreement until the Member’s paid annual membership terminates.
e) The Plan will post on its website (www.NewDentalChoice.com) the names of Participating Providers who (1) have given notice to Plan that they intend to withdraw from the Plan’s provider network; (2) are being terminated from the Plan; or (3) become unable to perform as a Participating Provider This notice under normal circumstances will be posted no less than sixty (60) days before the Provider will cease to be a Provider in the Plan, although in instances where the Provider is being terminated for reasons of cause or otherwise becomes unable to perform as a Provider, the website notice may be posted in fewer days. Therefore, Members are encouraged to consult the Plan’s website to determine the status of a particular Participating Provider, or they may call the Plan’s toll-free number and speak with a Member Services Representative (1-888-632-3676).
10. LIABILITY OF SUBSCRIBER AND MEMBER FOR PAYMENT:
The Plan is not liable for any Member costs incurred at Participating Providers or Non-Participating Providers. Should for any reason the Plan come to owe to a Participating Provider any sum, the Member shall not be responsible or liable to the Provider for any portion of such sums.
11. EMERGENCY SERVICES:
The Plan need not be notified in the event of an emergency. A Member requiring emergency Dental Care Service may receive Services from any Participating Provider by showing a valid Member I.D. card. The Plan does not provide for discounted fees from Non-Participating Providers. The plan is not liable for any Member costs incurred at Non-Participating Providers.
12. MEMBERSHIP ELIGIBILITY AND ADDING DEPENDENTS:
Upon receipt of the Plan Member I.D. card, a Member and Eligible Dependents shall be equally entitled to all discounts for the term of which the Subscriber has paid. Subscriber may add additional dependents by notifying Plan in writing and paying any relevant prorated monies for the remainder of Subscriber’s eligibility term. A Subscriber may include or add as a dependent a domestic partner provided the domestic partnership has been registered with the Office of the California Secretary of State.
13. RENEWAL PROVISIONS:
At the conclusion of the initial and subsequent Membership Terms, annual memberships in the Plan will be renewed automatically unless the Subscriber notifies the Plan, by providing written or e-mail notification to Plan at firstname.lastname@example.org prior to the new Membership term, that he/she wishes to cancel his/her Membership in the Plan. Subscribers with annual Memberships may pre-approve an automatic billing to their credit card to effect their renewal; Subscribers not authorizing automatic renewal will be mailed a renewal notice no less than 30 days prior to the end of their Membership term.
14. CANCELLATION AND NON-RENEWAL OF ENROLLMENT OR SUBSCRIPTION:
An enrollment or a subscription may be cancelled or not renewed by Plan for the following reasons:
(a) Failure to pay the Membership Fee if the Subscriber has been duly notified and billed for the Fee and at least 15 days have elapsed since the date of notification. Cancellation of membership will be effective upon the date of mailing the notice of cancellation.
(b) Fraud or deception in the use of the discounted fee Membership or knowingly permitting such fraud or deception by another. Cancellation of membership will be effective upon the date of mailing the notice of cancellation;
(c) If at any time we determine that you intentionally gave us incomplete or incorrect material information and our decision to accept your enrollment was based, in whole or part, on that misinformation, we may cancel your membership. Cancellation of membership will be effective upon the date of mailing the notice of cancellation.
(d) If a Participating Provider is unable, after reasonable effort, to establish and maintain a satisfactory dentist-patient relationship with a Member, and Member declines to seek desired dental services from another Participating Provider. Notice of such termination must be in writing by the Plan and eligibility will cease fifteen (15) days after receipt of postage-paid mailing of such notice. Following termination, the Plan will refund any Membership Fee received by it on behalf of such Member during the period of one (1) month prior to such termination.
(e) Upon a Dependent’s no longer living with and financially dependent upon the Subscriber, as determined by the Internal Revenue Service. Cancellation of Dependent’s membership will be effective on the last day of the month for which a prepayment fee was made on behalf of the Dependent.
(f) If eligibility lapses while a Member is undergoing treatment for an ongoing condition, the Member will have a thirty (30) day grace period for full reinstatement of eligibility without a lapse in coverage. (g) In the event the proper Membership Fee amount is paid after cancellation of the Subscriber, the Plan will reinstate the Subscriber without requiring a new application unless the Plan shall, within twenty (20) business days: 1) refund the payment made or 2) issue to the Subscriber a new enrollment form. Covered Services in Progress will continue until the Services are completed. A Subscriber who believes that his or her membership has been cancelled or non-renewed because of his or her dental health status or requirements for dental care services may request that such action be reviewed by the Director of the Department of Managed Health Care by contacting the Department at the telephone number stated in Paragraph 17 below. If after canceling this Agreement for nonpayment of the required Membership Fee Plan receives the Membership Fee within 30 days, Plan shall reinstate the Member as though the cancellation had never occurred; provided, however, that Plan need not reinstate the Member if payment is not received within 30 days of the issuance of the notice of cancellation; in such a case, a new application will be required and if accepted the original contract will be reinstated. The notice of cancellation will clearly state these conditions and procedures.
15. TERMINATION OF BENEFITS AND REFUND OPTIONS:
If, for any reason, a Subscriber is not satisfied with the Plan and wishes to terminate his/her Membership, the Subscriber may cancel the Membership within the first 30 (thirty) days by notifying the Plan in writing or by e-mail communication at email@example.com. Subscriber must also return his/her Member I.D. Card to Plan to receive a refund. Membership in the Plan shall terminate at midnight on the date that Plan receives the noticed cancellation. Activation fees collected at the time of enrollment are not refundable. Refunds shall be made through the same mode as the last payment received. Any cancellation of Membership in the Plan will not affect the completion of any Services in Progress.
16. MEMBERSHIP PAYMENT/BILLING:
Unless payment is made by check (other than by a direct debit to a checking account), payment of the initial Membership Fee and any renewal Membership Fee is made automatically by a direct charge against the Subscriber’s credit card or other payment option, previously authorized by the Subscriber, for the full amount of the Plan Membership Fee for the Membership Term. Members who choose to pay Membership Fees by a direct charge against the Subscriber’s credit card or other automatic payment option may authorize the Plan to automatically renew the Subscriber’s Membership at the end of the Member’s term by charging the Subscriber’s credit card or other automatic payment option. The Subscriber will be notified of the billing in his/her credit card or other statement. Plan reserves the right to increase the Membership Fee for a future Membership Term, in which case the Subscriber will be notified in writing of the increased Membership Fee, a minimum of thirty (30) days prior to the date of the new charge.
17. GRIEVANCE PROCEDURE/ARBITRATION:
If a Member has a grievance with the Plan or a Participating Provider concerning Provider accessibility or discounted fees under this contract, he or she may orally submit such grievance by calling the Plan Member Services Department at 1-888-NDC-ENROLL (1-888-632-3676). Plan will permit grievances which are filed within 180 days of the occurrence or incident that is the subject of the grievance. Member may also submit a completed written grievance form (available by calling the Member Services number, online at www.newdentalchoice.com, or from their Dentist’s office) or a detailed grievance summary of Member’s grievance to: New Dental Choice, c/o Membership Services Department, P.O. Box 919029 San Diego, CA 92191. The Chief Operating Officer of Plan shall have primary responsibility for overseeing the operation of Plan’s grievance procedures. All grievances will be addressed within 48 business hours of receipt. The Plan shall not discriminate against any Member because of race, color, national origin, ancestry, religion, sex, martial status, sexual orientation, genetic characteristics, mental, or physical abilities when filing a grievance. Furthermore, the Plan will not discriminate against any member who has engaged the grievance procedure at any level, for any reason. The California Department of Managed Health Care is responsible for regulating discounted fee plans. If a Member has a grievance against the Plan, Member should first contact the Plan at 1-888-NDC-ENROLL (1-888-632-3676) and attempt to resolve the grievance through the Plan’s grievance process before contacting the Department. Utilizing this grievance procedure does not negate any potential legal rights or remedies that may be available to Member. If Member needs help with a grievance that has not been satisfactorily resolved by the Plan, or with a grievance that has remained unresolved for more than 30 days, Member may call the Department for assistance. The Department has a toll-free number (1-888-466-2219) 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 and instructions online.
Each and every disagreement, dispute or controversy which remains unresolved concerning Provider accessibility or discounted fees under this contract after exhausting Plan’s complaint procedures, arising between a member or the heir-at-law or personal representative of such person, as the case may be, and Plan, its employees, officers or directors, or Participating Provider or Members, partners, agents, or employees, may be voluntarily submitted to arbitration in accordance with the rules and regulations of the American Arbitration Association. Arbitration shall be initiated by written notice to the President of First Dental Health, Inc., P.O. Box 919029, San Diego, California 92191. This notice shall include a detailed description of the matter to be arbitrated.
19. PUBLIC POLICY COMMITTEE:
The Plan encourages participation by Members in the Plan’s Public Policy Committee. The Public Policy Committee meets quarterly and Plan appoints selected Members to serve for a period of two (2) years. The Public Policy Committee establishes Public Policy issues with the Plan, evaluates Plan performance as it relates to membership and reviews Plan materials. Interested Members are requested to contact the Plan’s administrative office for further information.
20. MEMBER REPRESENTATIONS AND ACKNOWLEDGEMENTS:
Subscriber makes the following representations and acknowledgements:
a) Subscriber has read this Agreement carefully, understands the Plan, and understands the various billing methods for payment of the Membership Fee.
b) Subscriber may cancel his/her Plan Membership within the first 30 (thirty) days of the Membership Term and will be entitled to a refund subject to the terms of Paragraph 15 of this Agreement.
c) Unless Subscriber cancels his/her Membership in accordance with Paragraph 15 of this Agreement, the Plan Membership will be automatically renewed on the last day of Subscriber’s Membership Term, and payment of the Plan Membership Fee for the new Membership Term will be made by a direct charge against Subscriber’s credit card or other automatic payment option.
d) Membership in the Plan and services thereunder are not assignable without the express written consent of the Plan. Subscriber agrees that he/she will use his/her Plan Membership only for his/her personal benefit or for the benefit of his/her Eligible Dependents. A violation of this paragraph 19(d) will result in immediate termination of the Plan Membership.
e) Subscriber understands that Members are responsible for paying Participating Providers for services rendered at time of service unless otherwise agreed upon by Member and Participating Provider.
f) A statement describing the FDH policies and procedures for preserving the confidentiality of dental records is available and will be furnished to you upon request.
21. DISCLAIMER OR WARRANTIES:
The Plan is not a merchant, manufacturer, or a direct provider of the Dental Care Services available to Members. In the event any product or Dental Care Service purchased by a Member is cancelled, modified, defective, or otherwise unsatisfactory to the Member, the Member will look solely to the Provider, seller, merchant, or manufacturer of the product or service for any repair, exchange, refund, or satisfaction of claim.
The Plan shall not discriminate against any Member because of race, color, national origin, ancestry, religion, sex, martial status, sexual orientation, genetic characteristics, mental, or physical abilities.
23. GENERAL RELEASE:
Each Subscriber for himself/herself, and on behalf of any Eligible Dependent who uses the Services under the Plan Membership, hereby forever releases, acquits and discharges each of FDH, its employees or agents from any and all liabilities, claims, demands, actions, and cause of action that such Member may have by reason of any monetary damage or personal injury sustained as a result of, or during the cause of the use of any and all Services under The Plan.
Any and all notices, consents, approvals, requests, and other written communications given or required under the terms of this Agreement shall be deemed to have been duly given and served when sent by first class mail, postage-prepaid and addressed to the Member at the address shown on the Member I.D. Card, or to Plan at: New Dental Choice, P.O. Box 919029, San Diego, CA 92191.
25. ENTIRE AGREEMENT:
This Agreement sets forth the entire agreement and understanding of the parties with regard to membership in the Plan. No representations, inducements, promises or agreements, or otherwise, shall be of any force or effect. The validity or unenforceability of any term of this Agreement shall in no way affect the validity or enforceability of any other terms or provisions or this Agreement.
26. BINDING EFFECT:
This Agreement shall be binding upon and inure to the benefit of the parties as well as their respective successors and permitted assigns.
27. GOVERNING LAW:
This Agreement shall be governed and construed in accordance with the laws of the State of California.
The headings or captions provided throughout this Agreement are for reference purposes only and shall in no way affect the meaning or interpretation of this Agreement.
This agreement may be amended only in writing executed by the parties.
30. WAIVER OF BREACH:
Waiver of breach of any provision of this Agreement shall not be deemed a waiver of any other breach of the same or different provision.