PREPAYMENT FEE

In consideration of the dental benefits provided by LIBERTY Dental Plan (LIBERTY), the Subscriber shall pay LIBERTY the standard premium plus any enrollment fee based on the Benefit Plan selected. The payment due to LIBERTY shall be paid yearly in advance. If any check for payment is returned for insufficient funds, the Subscriber agrees to pay LIBERTY a fee of $30.

OTHER CHARGES

In addition to paying the prepayment fee referred to above, the receipt of certain types of dental benefits, as specified in the Benefit and Co-Payment document for the Benefit Plan, may require the member to make a co payment to the network dentists.

FACILITIES

All services and benefits under our Dental Plans are covered only if provided by a contracted LIBERTY Dental Plan participating Primary Care Dentist or if referred to a Dental Specialist by LIBERTY Dental Plan. The only time you may receive care outside of the network is for true emergency dental services necessary when you are out-of-the area or cannot contact your Primary Care Dentist or LIBERTY Dental Plan. LIBERTY Dental Plan will reimburse you for true emergency dental treatment expenses up to a maximum of $75.00 per year, less applicable co-payments.

The name, address, and telephone number of each participating dentist is available on the LIBERTY Web Site or by calling member services. The provider will be available for appointments during office hours. Should the member have any questions regarding the days and hours of the offices of a network dentist, the member should call their network dentist directly.

RENEWAL PROVISIONS

LIBERTY has contracted to provide dental benefits to the Subscriber for a period of one year. The contract may thereafter be renewed at the discounted renewal rate for the selected Benefit Plan within 30 days of the original contract expiration, unless the original Benefit Plan has been terminated. If more than one calendar month has passed since the original contract expiration, a new Benefit Plan can be purchased at the standard premium rate.

In the event that the Subscriber’s Benefit Plan is no longer available from their network dentist or LIBERTY, the Subscriber has the option to select another Benefit Plan from LIBERTY.

REFUND POLICY

If the Subscriber is eligible for a refund upon cancellation or termination of the agreement, LIBERTY will return to the Subscriber the pro rata portion of the Premium for any unexpired period for which payment has been received, not to exceed 9 months of premium refund. Any Enrollment or Activation Fee Paid (typically $20) will not be refunded. All refunds will be issued within 30 days of receipt of the notice of cancellation.

TERMINATION OF BENEFITS

Subject to the Enrollee Complaint Procedure provision, an eligible Subscriber or eligible dependent's enrollment under this Program may be cancelled or renewal of enrollment refused.

LIBERTY may cancel or terminate the agreement in the following scenarios:
  1. Loss of eligibility as described in the Evidence of Coverage
    • Cancellation is effective immediately upon receiving written notice regarding the loss of eligibility
    • Subscriber is eligible for a refund in accordance with the refund policy
    • Coverage for the Subscriber and his/her dependents shall cease effective the last day of the month in which the termination occurred
  2. Loss of dependent status
    • Cancellation is effective immediately upon receiving written notice regarding the loss of eligibility
    • Subscriber is eligible for a refund in accordance with the refund policy
    • Coverage for the Subscriber and his/her dependents shall cease effective the last day of the month in which the termination occurred
  3. Subscriber engages in conduct detrimental to safe operations and the delivery of services while in a network dentists’ facility
    • Cancellation is effective upon 15 days written notice from LIBERTY to the Subscriber
    • Subscriber is eligible for a refund in accordance with the refund policy
    • Coverage for the Subscriber and his/her dependents shall cease effective the last day of the month in which the termination occurred
  4. Failure to pay prepayment fee
    • Cancellation is effective upon 15 days written notice from LIBERTY to the Subscriber
    • Subscriber is not eligible for a refund
    • Subscriber may continue to receive benefits during the 15-day period and may be reinstated during the term of Contract upon payment of any unpaid premium
  5. Subscriber knowingly commits or permits another person to commit fraud or deception in obtaining benefits under the Program
    • Cancellation is effective upon 15 days written notice from LIBERTY to the Subscriber
    • Subscriber is not eligible for a refund
    • Coverage for the Subscriber and his/her dependents shall cease effective the last day of the 15 day period
A Subscriber may cancel the agreement and receive a refund in accordance with the refund policy under the following conditions:
  1. No Contract Dentist is available to the Subscriber
  2. The Subscriber has moved out of the LIBERTY of California service area for the remainder of the plan year. This must be a change of primary residence and does not include travel.
  3. The Subscriber changes to a coverage under a group program
Cancellation notices from the Subscriber must be sent to LIBERTY 30 days in advance in writing via email, mail or fax.
Please include the following in the cancellation notice:
  • Name
  • Member ID
  • Mailing address
  • Email address
  • Phone number
  • Reason for Cancellation
Cancellation requests can be sent to LIBERTY at:
Email: eligibility@libertydentalplan.com
Mail: LIBERTY Dental Plan
Attn: Eligibility Department
340 Commerce, Suite 100
Irvine, CA 92602
Fax: LIBERTY Dental Plan
Attn: Eligibility Department
(949) 223-0011

Cancellation of a Subscriber's enrollment, as described above, shall automatically cancel the enrollment of any of his or her Dependent Enrollees. Any cancellation is subject to the written notification requirements set forth in this Contract.

If the Subscriber believes that enrollment has been cancelled or not renewed because of their health status or requirements for health care services, or that of the Subscriber’s dependent(s), the Subscriber may request a review by the Director of the California Department of Managed Health Care of the State of California. Please refer to enrollee complaint procedure.

PREPAYMENT FEE

In consideration of the dental benefits provided by LIBERTY Dental Plan (LIBERTY), the member shall pay LIBERTY the standard premium. The payment due to LIBERTY shall be paid yearly in advance.

OTHER CHARGES

In addition to paying the prepayment fee referred to above, the receipt of certain types of dental benefits, as specified in the Copayment Schedule document for the benefit plan, may require the member to make a copayment to the network dentists.

DENTAL FACILITIES

All services and benefits under our dental plans are covered only if provided by a LIBERTY participating network dentist or if referred to a dental specialist by LIBERTY. If you experience a dental emergency and are unable to reach your network dentist, LIBERTY will reimburse you for qualified emergency dental expenses up to a maximum of $75.00 per year less applicable copayments.

A complete directory of our network dentists is available on the LIBERTY website or by calling LIBERTY Member Services at (877) 877-1893. The network dentist will be available for appointments during office hours. Should the member have any questions regarding the days and hours of the offices of a network dentist, the member should call their network dentist directly.

RENEWAL PROVISIONS

LIBERTY has contracted to provide dental benefits to the member for a period of one year. The contract may thereafter be renewed at the annual rate for the selected benefit plan.

REFUND POLICY

If the member is eligible for a refund upon cancellation or termination of the agreement, LIBERTY will return to the member the pro rata portion of the premium for any unexpired period for which payment has been received, not to exceed 9 months of premium refund. All refunds will be issued within 30 days of receipt of the notice of cancellation in writing.

TERMINATION OF BENEFITS

Subject to the Enrollee Complaint Procedure provision, an eligible member or eligible dependent's enrollment under this program may be cancelled or renewal of enrollment refused.

LIBERTY may cancel or terminate the agreement in the following scenarios:
  1. Loss of eligibility as described in the Evidence of Coverage
    • Cancellation is effective immediately upon receiving written notice regarding the loss of eligibility
    • Member is eligible for a refund in accordance with the refund policy
    • Coverage for the member and his/her dependents shall cease effective the last day of the month in which the termination occurred
  2. Loss of dependent status
    • Cancellation is effective immediately upon receiving written notice regarding the loss of eligibility
    • Member is eligible for a refund in accordance with the refund policy
    • Coverage for the member and his/her dependents shall cease effective the last day of the month in which the termination occurred
  3. Member engages in conduct detrimental to safe operations and the delivery of services while in a network dentists’ facility
    • Cancellation is effective upon 15 days written notice from LIBERTY to the member
    • Member is eligible for a refund in accordance with the refund policy
    • Coverage for the member and his/her dependents shall cease effective the last day of the month in which the termination occurred
  4. Failure to pay prepayment fee
    • Cancellation is effective upon 15 days written notice from LIBERTY to the member
    • Member is not eligible for a refund
    • Member may continue to receive benefits during the 15-day period and may be reinstated during the term of contract upon payment of any unpaid premium
  5. Member knowingly commits or permits another person to commit fraud or deception in obtaining benefits under the program
    • Cancellation is effective upon 15 days written notice from LIBERTY to the member
    • Member is not eligible for a refund
    • Coverage for the member and his/her dependents shall cease effective the last day of the 15 day period
A member may cancel the agreement and receive a pro-rated refund in accordance with the refund policy under the following conditions:
  1. No network dentist is available to the member
  2. The member has moved out of the LIBERTY of Florida service area for the remainder of the plan year. This must be a change of primary residence and does not include travel.
  3. The member changes to a coverage under a group program
Cancellation notices from the Subscriber must be sent to LIBERTY 30 days in advance in writing via email, mail or fax.
Please include the following in the cancellation notice:
  • Name
  • Member ID
  • Mailing address
  • Email address
  • Phone number
  • Reason for Cancellation
Cancellation requests can be sent to LIBERTY at:
Email: eligibility@libertydentalplan.com
Mail: LIBERTY Dental Plan
Attn: Eligibility Department
P.O. Box 26110
Santa Ana, CA 92799-6110
Fax: LIBERTY Dental Plan
Attn: Eligibility Department
(949) 223-0011

Cancellation of a member's enrollment, as described above, shall automatically cancel the enrollment of any of his or her dependent enrollees. Any cancellation is subject to the written notification requirements set forth in this contract.

If the member believes that enrollment has been cancelled or not renewed because of their health status or requirements for health care services, or that of the member’s dependent(s), the member may request a review by the Florida Department of Financial Services. Please refer to Enrollee Complaint Procedure.

The Florida Department of Financial Services
Office of Insurance Regulation, Division of Consumer Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone 1-877-693-5236