Description of services and disclosure form



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Discount Dental Plan

A Flexible Alternative to Insurance

DESCRIPTION OF SERVICES AND DISCLOSURE FORM


The following is a Description of the Discount Dental Plan available to you and your family members through The Center of Dental Professionals. The Description thoroughly describes the plan and your rights under the plan, and if you choose to enroll it is your contract with The Center of Dental Professionals. You should read this carefully. PLEASE READ THE FOLLOWING INFORMATION REGARDING FROM WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE CAN BE OBTAINED. If you have any questions about this Description, please call The Center of Dental Professionals at (801) 747-8018.

  1. Contact Information: The full name of the plan is The Center of Dental Professionals Discount Dental Plan (hereafter referred to as “CDP”). We have two locations to serve you:


Downtown Location

530 East 500 South

Salt Lake City, Utah 84102

Phone: (801) 747-8018


South Salt Lake Location

3798 South 700 East Suite 6

Salt Lake City, Utah 84106

Phone: (801) 747-8015


Our website is www.dentalprosutah.com, and our email address is info@dentalprosutah.com


  1. Type of Plan: This is a discount fee plan. THE DENTAL DISCOUNT PLAN IS NOT INSURANCE. By paying an annual enrollment fee to CDP (see Section 10), you (and if applicable, your eligible family members) will be entitled to receive dental services at reduced rates. A complete description of the reduced rates for dental services is outlined in Section 11 of the Description.




  1. Definitions:

Eligibility: your or your family’s rights to receive dental services at reduced rates.

Eligible family member's: legal spouse and dependent children who are under age 18 (or under age 23 if attending school on a full-time basis), or who are incapable of self-sustaining employment because of a physical or mental disability, injury, illness, or condition, and who are dependent on you for support and maintenance.
Network Dentist: a dentist who has agreed with CDP to provide services at the reduced rates outlined in this Description.
Specialist Services: periodontics, endodontics, and oral surgery.
Specialist: a dentist who performs only a specialist service.



  1. Choice of Dentists: To be entitled to the reduced rates, you and your eligible family members must visit a Network Dentist. If you receive services from a dentist who is not a network Dentist, you will not be entitled to the discount fees provided by the plan. You can visit any Network Dentist, including the Network Dentists whose names and addresses included in this brochure. If you want the name and location of other nearby Network Dentists, or if you have a question about CDP’s Network Dentists, please call CDP at (801)747-8018.




  1. The scope of Eligibility: You can select eligibility for yourself, for you and your spouse, or for you and all of your eligible family members.




  1. Commencement of Services: Once you have read through this Description, complete the Enrollment Form included in this brochure. The completed Enrollment Form must be sent to CDP (at the address set forth on the Form) along with your payment for the one-time processing fee and the initial annual enrollment fee. The Enrollment Form can be completed in one of the designated facilities and turned into a designated staff member. Debit or credit card are the only accepted form of payment per the monthly agreement. Annual membership fees, can be made by cash, debit or credit card.


Once your Enrollment Form and fees are received and processed, CDP will send you an identification card. If you select services for your eligible family members, they will also receive an identification card. Eligibility begins when CDP receives your processing fee and monthly or annual fees.

You must present your identification card to your Network Dentist before you receive treatment unless you are applying for the Dental Discount Program in office enrollment, at which time discounts could be immediately applied.


  1. Term and Termination of Services: Your and your eligible family members’ right to receive services will continue for one year from the time CDP receives your initial enrollment fee. The termination date will appear on your identification card and will end at midnight on that date.

Other Causes of Termination of Eligibility Prior to the 1 Year Mark:

    1. Eligibility for your spouse will terminate upon the legal date of divorce

    2. Eligibility for any child will terminate once the child exceeds the age limit described in Section 3

      1. If upon reaching the age limit in Section 3, your child is incapable of self-sustaining employment because of a mental or physical disability, injury, illness, or condition, and is chiefly dependent on you for support and maintenance, then eligibility for that child will continue through the term of your enrollment and re-enrollment. However, you must furnish proof to CDP of such incapacity and dependency within sixty (60) days after you receive notice that your child’s eligibility will terminate. Such notice will be given at least ninety (90) days before your child reaches the limiting age. CDP will make a determination of your child’s incapacity and dependency status, and will so notify you before your child’s eligibility ends. If CDP fails to notify you of its determination by such time, your child’s eligibility will continue until you receive such notice.

Your right to receive services at the discounted fees described in this plan will end at the expiration of your one-year term unless you re-enroll as outlined in section 8. Upon termination, your Network Dentist will complete all procedures started before termination at the rates described in section 11.




  1. Renewal of Eligibility: You can renew your right to receive discounted fee services for an additional year by paying an annual re-enrollment fee to CDP before your initial eligibility terminates. CDP will send you a written notice about this at least thirty (30) days before the expiration of eligibility. The re-enrollment fee may be different from the initial annual enrollment fees described in Section 10. You will be notified what the applicable fee is on your renewal notice. Upon re-enrollment, you (and any other eligible parties) will receive a new identification card.

The same procedure will be used to re-enroll for succeeding years. Other than payment of the required fee, there are no conditions or restrictions on your right to re-enroll.


Cancellation of Services: You will have forty-five (45) days after your fees are paid to cancel your eligibility and receive a full refund of your enrollment fee. To receive your refund, you must submit a written request for the cancellation and refund. The refund will not include the processing fee.
No cancellation will be permitted if you or any of your eligible family members receive services from a Network Dentist during this 45-day period. If the forty-five (45) day mark has already passed, you cannot cancel enrollment or re-enrollment and receive any refund of your enrollment or re-enrollment fee.
You can terminate your eligibility after any one-year period simply by choosing not to re-enroll. CDP cannot cancel your enrollment or refuse to permit you from re-enrolling after any one-year period ends unless you or any of your eligible family members has engaged in fraud in using this plan. However, if you believe that CDP has canceled your enrollment or refused to re-enrollment because of you or any eligible family member’s health status, you may contact the Utah Insurance Department at (801) 538-3800 or contact the Department via email at hdp@utah.gov.


  1. Processing and Enrollment Fees: Upon enrollment, you will pay an initial enrollment fee and a one-time processing fee of $50.00. You will pay the one-time processing fee and the first enrollment fee through your preferred credit card or other payment method as described in the Enrollment Form that follows this Description. Applicable enrollment fees for the initial year of services are as follows:

Individual Annual: $165.00

Individual Monthly: $14.58

Child Annual: $95.00



Child Monthly: $8.75
As noted in Section 8, re-enrollment fees for years after your initial year of services may be different.


  1. Dental Services and Fees: Following this Description is a complete list of covered dental services and fees your Network Dentist will charge for these services. Please note that this is the fee schedule currently in effect in your area. CDP reserves the right to change the fee schedule at any time, and any new fee schedule will apply to all dental services received by you or your family members thirty (30) days after CDP mails you written a notice of the new schedule.




  1. Other Charges: There are no other charges of any kind under this plan. All you have to do is pay your network Dentist for the discounted services that you or your eligible family members receive.




  1. Limitations and Exclusions: The following is a complete list of all limitations and exclusions under this Plan:



Discounts for treatments of fractures or dislocations, congenital malformations, malignancies, cysts or neoplasms, or Temporomandibular Joint Syndrome (TMJ)

Excluded

Discounts for prescription drugs and over the counter drugs

Excluded

Prophylaxis (cleaning)

Once every 6 months

Full mouth x-rays

Once every 24 months

Replacement of partial dentures

Once every 5 years

Full upper and/or lower dentures

Not to exceed one each in any 5-year period

Denture relines

One per arch every 12 months

Services performed by a non-participating provider

Excluded

Work in progress that has commenced prior to enrollment must be completed by the dentist who started the work (whether or not a Network Dentist)


Excluded



  1. Your Responsibility for Payment and Fees: Once you or any of your eligible family members receive services from a Network Dentist, your Network Dentist will bill you directly for those services at the rates outlined in the Fee Schedule. You will pay the billed amount to your Network Dentist. This is a discount dental fee plan only. No amounts are payable by CDP either to you or your Network Dentist.




  1. Disputes: CDP maintains a grievance system to handle any dispute or grievance you may have with your Network Dentist or with CDP itself. You have one-hundred-eighty (180) days after any incident or action to submit a grievance. CDP will acknowledge the receipt of your grievance within five (5) calendar days after CDP receives it and will notify you of the resolution of your grievance within thirty (30) days after receipt. If you are not satisfied by CDP’s resolution of your grievance, you may seek review of the Utah Insurance Department at (801) 538-3800 or contact the Department via email at health.uid@utah.gov. For a complete description of CDP’s grievance system, please visit our website at www.dentalprosutah.com.

  1. You may obtain a grievance form from your Network Dentist and submit it in writing to the address listed in Section 1.

  2. You may complete a grievance form online at www.dentalprosutah.com

  3. You may submit a grievance by email to CDP at info@dentalprosutah.com.

Utah law requires CDP to provide you with the following notice:

The Utah Insurance Department is responsible for regulating discounted fee plans. If you have a grievance against your plan, you should first contact your plan and use your plan’s grievance system 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 that has not been satisfactorily resolved by the plan, or with a grievance that has remained unresolved for more than thirty (30) days, you may call the Department for assistance.

The Department has an in-state toll-free telephone number (800) 439-3805. If calling from out of state, please use their (801) 538-3800 number. The Department’s website is https://insurance.utah.gov and their complaint forms and instructions may be found.

  1. Specialist Services: Some Specialist Services may need to be performed by a Specialist and not all Network Dentists provide Specialist Services. Note that you will receive the discounted fees for Specialist Services under this Plan only if those services are received from a Network Dentist. If your Network Dentist does not provide Specialist Services, you may contact CDP to see if the there is a nearby Network Dentist who can perform the Specialist Services. You do not need a referral from CDP to see a Network Dentist who provides such services.




  1. Office Hours and Emergency Services: Your Network Dentist will be available during regular CDP business hours, Monday through Friday. Your Network Dentist will arrange for emergency dental care, which will be available twenty-four (24) hours a day, seven (7) days a week. If you need after-hours care, call your Network Dentist, and you will be given instructions on how to proceed. You may also contact CDP for assistance with after-hours care.




  1. Termination of Network Dentist: If your Network Dentist is no longer in network and CDP has a record of who your Network Dentist is, CDP will promptly notify you so that you can make arrangements to see another Network Dentist. CDP will also post a notice on its website listing all Network Dentists who have given notice of termination, terminated, or who otherwise are unable to provide services. The notice will state the effective date of termination. As always, you may contact CDP for information on whether or not your dentist is still a Network Dentist.

CDP’s contract with each Network Dentist specifies that upon termination of the contract, the Network Dentist must complete all procedures commenced before termination at the discounted rates outlined in Section 11. If CDP should ever cease operations, your Network Dentist will continue to render discount services to you and your eligible family members for the duration of your enrollment.


  1. If you have Dental Insurance: Since CDP does not provide insurance, it does not coordinate benefits with any dental insurance you or your family members may have. If you have dental insurance, you should contact your dental insurer for information on what benefits will be paid.




  1. Application of State Law: CDP is subject to the requirements of Title 31A Chapter 8a. Rule R590-152 Health Discount Programs and Value Added Benefit Rule, and any provision required to be in the contract by either of the above shall bind CDP whether or not provided in this Description. Please see this on the Department website at https://insurance.utah.gov/health/discount.php .




  1. Confidentiality: Each Network Dentist and CDP itself is required by law to keep your personal healthcare information confidential. No such information can be released except with your written consent or as expressly authorized by law. A statement describing our policies and procedures for preserving the confidentiality of medical records is available upon request.




  1. Summary of Discounts: The following is a summary of the major categories of dental services available under this Plan and the average fee discount for each category of services. The average discount is the difference between what your Network Dentist charges and what a typical dentist customarily charges, as determined by the National Dental Advisory Service.

THIS IS ONLY A SUMMARY. PLEASE CONSULT THE FEE SCHEDULE TO DETERMINE THE EXACT FEE FOR ANY PARTICULAR DENTAL SERVICE.



Category

Average Plan Discount

Diagnostic

72 %

Preventive

40%

Restorative

42%

Endodontics

32%

Periodontics

29%

Prosthedontics (removable)

50%

Maxillofacial Prosthetics

52%

Implant Services

39%

Prosthedontics (fixed)

43%

Oral & Maxillofacial Surgery

61%

Adjunctive Services

47%

Utah State Law requires all health care service plans to give members of the public the following information regarding the applicability of any limitations on:

Deductibles

None

Lifetime Maximums

None

Professional Services

Dental Services Only

Outpatient Services

Not Applicable

Hospitalization Services

Not Applicable

Emergency Health Coverage

Available 24/7

Ambulance Services

Not Applicable

Prescription Drug Coverage

Not Applicable

Durable Medical Equipment

Not Applicable

Mental Health Services

Not Applicable

Chemical Dependency Services

Not Applicable

Home Health Services

Not Applicable

Other

Not Applicable

By completing and submitting this enrollment form, you agree to all terms and conditions as previously set forth in this Description.

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Applicant Signature Date

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Print Name


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