DESCRIPTION OF SERVICES AND DISCLOSURE FORM PLAN CONTRACT
The following is a description (this “Description”) of the discount dental plan available to you and your family members through The CDI Group, Inc. (“CDI”). This Description completely describes the plan and your rights under the plan, and if you choose to enroll it is your contract with CDI. You should read this carefully. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED. If you have any questions about this Description please call The CDI Group, Inc. at 1-855-257-2533.
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You can get an interpreter at no cost to talk to your dentist or dental plan. To get an interpreter or to ask about written information in your language first call your dental plan’s phone number at 1-855-257-2533. Someone who speaks your language can help you. If you need more help, call the HMO Help Center at 1(888) HMO-2219.
IMPORTANTE: Usted puede obtener un intérprete sin costo alguno para hablar con su dentista o plan dental. Para conseguir un intérprete, o para preguntar acerca de la información escrita en su idioma primero llame al número de teléfono de su plan dental al 1-855-257-2533. Alguien que hable su idioma le puede ayudar. Si necesita más ayuda, llame al Centro de Ayuda HMO al 1(888) HMO-2219.
1. Contact Information. The full name of the plan organization is The CDIGroup, Inc. The CDI Group, Inc. is located at 601 E. Daily Drive, Suite 215, Camarillo, CA 93010. The plan organization phone number is 1-855-257-2533.
2. Type of Plan. This is a discount medical plan. THIS IS NOT INSURANCE. By paying an annual enrollment fee to CDI (see Section 10 below) you (and if applicable your eligible family members) will be entitled to receive dental services at reduced rates from participating dentists. CDI does not make payments to any dentists. Plan members are required to pay for all services received, at the reduced rates. A complete description of the reduced rates for dental services is set forth in Section 11 below.
3. Definitions. As used in this Description, “Eligibility” means you or your family’s right to receive dental services at reduced rates. “Eligible family members” means your spouse and your dependent children who are under age 26, or who are incapable of self-sustaining employment by reason of a physical or mental disability, injury, illness, or condition, and who are dependent on you for support and maintenance.“Network Dentist” means a dental office which has agreed with CDI to provide services at the reduced rates set forth in this Description. “Specialist services” are periodontics, endodontics, orthodontics, and oral surgery. “Specialist” is a dentist who performs only a specialist service.
4. 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. If you want the name and location of other nearby Network Dentists, or if you have a question about CDI’s Network Dentists, just call CDI at 1-855-257-2533.
5. Scope of Eligibility. You can select eligibility for you alone, for you and your spouse, or for you and all of your eligible family members.
Commencement of Services. Once you have read through this Description, you should complete the Enrollment Form on-line or included in your brochure. If you complete the Form in the brochure you should send it to CDI at the address set forth on the Form along with your payment for the one-time processing fee and the initial annual enrollment fee. Payment may be made by check or credit card. Once your Enrollment Form and fees are received and processed, CDI will send you an identification card. If you elect services for your eligible family members they will receive identification cards as well. Eligibility begins when you receive your identification card. You must present your identification card to your Network Dentist before you receive treatment.
You will be eligible as soon as you enroll. If you have enrolled at a Network Dentist’s office you can receive discounted services immediately even though you have not received your Identification Card(s). In all other cases, if you or your eligible family members need dental services before your Identification Cards are received, just ask your Network Dentist to call CDI to confirm your eligibility.
6. Term and Termination of Services. You and your eligible family members’ right to receive services will continue for one year from the time CDI receives your initial annual enrollment fee. The termination date will appear on your identification card, and will end on midnight on that date. However, eligibility for your spouse will terminate upon your divorce from him or her, and eligibility for any child will terminate once the child exceeds the age limit described in Section 3 above.
Notwithstanding the above, 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 any re-enrollment. However, you must furnish proof to CDI 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. CDI will make a determination of your child’s incapacity and dependency status, and will so notify you, before your child’s eligibility ends. If CDI fails to notify you of its determination by such time, your child’s eligibility will continue until you receive such notice.
If you acquire an eligible family member during the term of your contract (for example, you get married), you can add that family member to your contract simply by
calling CDI at 1-855-257-2533. If the addition of a family member would cause an increase in your annual fee (see Section 10 below) you must pay the difference between the two rates, which will be prorated based upon the remaining months under your contract.
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 reenroll as described in Section 8 below. Upon termination your Network Dentist will complete all procedures started prior to termination at the rates set forth in Section 11.
7. 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 CDI before your initial eligibility terminates. CDI will send you a written notice about this at least thirty (30) days prior to the expiration of eligibility. The re-enrollment fee may be different from the initial annual membership enrollment fees described in Section 10 below. You will be told what the applicable fee is in your renewal notice. The re-enrollment fee is solely for the privilege of membership; no service charge for the process of re-enrollment will be assessed. Upon re-enrollment you (and if applicable your eligible family members) will receive new identification cards.
The same procedure will be used to reenroll for succeeding years. Other than payment of the required re-enrollment fee, there are no conditions or restrictions on your right to reenroll.
8. Cancellation of Services. You will have forty-five (45) days after you receive your identification card(s) to cancel your eligibility and receive a full refund of your enrollment fee (but not the processing fee). You may also cancel at any time after this initial 45-day period, in which case you will receive a pro rata refund of your enrollment fee.
However, no cancellation will be permitted if you or any eligible family member received plan services from a Network Dentist. To receive your refund you must return to CDI (at the address in Section 1 above) all identification cards that were given to you and your family members, along with a written request for the refund. Refunds will be made within thirty (30) days.
Other than as stated above, you cannot cancel any enrollment or re-enrollment and receive any refund of your enrollment or re-enrollment fee. However, you can terminate your eligibility after any one-year period by simply choosing not to reenroll.
CDI cannot cancel your enrollment, or refuse to permit you to reenroll after any one-year period of eligibility ends, unless you or any of your eligible family members has engaged in fraud in using this plan. However, if you believe that CDI has cancelled your enrollment or refused re-enrollment because of your or any family member’s health status, you may contact the California Department of Managed Health Care at 1-888-HMO-2219 (for hearing or speech impaired persons at 1-877-688-9891) or contact the Department on-line at www.hmohelp.ca.gov.
9. Processing and Enrollment Fees. Upon enrollment you will pay a one-time processing fee of $15.00 and your initial enrollment fee. Applicable membership enrollment fees for the initial year of services are as follows:
You Only: $59.00 | Additional Member(s): $20.00
As noted in Section 8, re-enrollment fees for years after your initial year of services may be different.
You will pay the one-time processing fee and the initial enrollment fee through your preferred credit card or other payment method as described in the Enrollment Form that follows this Description.
10. Dental Services and Fees. Following this Description is a complete list of covered dental services and the fees your Network Dentist will charge for these services.
Please note that this is the fee schedule currently in effect for your area. CDI 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 CDI mails you written notice of the new schedule.
11. Other Charges. There are no copayments, deductibles, or other charges of any kind under this plan. All that you have to do is pay your Network Dentist for the discounted services that you or your eligible family members receive.
12. Limitations and Exclusions. The following is a complete list of all limitations and exclusions under this Plan:
• Dentures or partials-replacement is once every five (5) years from initial placement or replacement and only if existing denture is unsatisfactory and cannot be made satisfactory.
• Fluoride treatment is limited to once per year.
• Prophylaxis (Cleaning) is limited to once every six months.
• Full mouth x-rays are limited to once every 24 months.
• Relines are limited to two per year.
• Dentistry for cosmetic purposes unless it is listed on the dental plan.
• Discounts for prescription drugs and over the counter drugs are not
• General anesthesia & conscious sedation are not discounted.
• Replacement for lost dentures or bridgework are not discounted.
• Services performed by a non-participating provider are not covered.
• Discounts for treatments of fractures or dislocations, congenital
malformations, malignancies, cysts or neoplasms, or Temporomandibular Joint Syndrome (TMJ) are not provided.
14. Your Responsibility for Payment of 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 set forth in the Fee Schedule. You will pay the billed amount to your Network Dentist.
If CDI should ever become liable to your Network Dentist for any reason, your Network Dentist will not hold you responsible for such liability.
This is a discount dental fee plan only. No amounts are payable by CDI either to you or to your Network Dentist.
15. Disputes. CDI maintains a grievance system to handle any dispute or grievance you may have with your Network Dentist or with CDI itself. You can obtain a grievance form from your Network Dentist or you can complete a grievance form online at https://dentalalliancedentalplan.com/support.
You can submit a grievance in writing, by email, or by telephone. CDI’s address is 601 E. Daily Drive, Suite 215, Camarillo, CA 93010, and its telephone number is 1-855-257-2533. You may submit a grievance by email to CDI at email@example.com.
You have one year to file a grievance after any incident or action. CDI will acknowledge receipt of your grievance within five (5) calendar days after CDI receives it. CDI will notify you of the resolution of your grievance within thirty (30) days after receipt.
If you are not satisfied with CDI’s resolution you can seek review from the Department of Managed Health Care at 1-888-HMO-2219 (for hearing or speech impaired persons at 1-877-688-9891) or contact the Department on-line at www.hmohelp.ca.gov.
For a more complete description of CDI’s grievance system please visit CDI’s website at https://dentalalliancedentalplan.com/support.
California law requires CDI to provide you with the following notice:
“The California Department of Managed Health Care is responsible for regulating discounted fee plans. If you have a grievance against your plan, you should first telephone your plan at 1-855-257-2533 and use your 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 that has not been satisfactorily resolved by the Plan, or with 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.”
16. Specialist Services. Not all Network Dentists provide specialist services, and some specialist services may need to be performed by a specialist. 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 can call CDI to confirm where the closest Network Dentist providing specialist services is located. You do not need a referral from CDI to see a Network Dentist who provides such services.
17. Office Hours and Emergency Services. Your Network Dentist will be open during normal work hours, Monday through Friday. Your Network Dentist will arrange for emergency dental care, which will be available 24-hours a day, 7-days a week. If you need after-hours care, call your Network Dentist and you will be told what to do. You can also call CDI at 1-855-257-2533 for assistance with after-hours care.
18. Timely Access to Care. If you ever need to schedule or reschedule an appointment, your Network Dentist’s office will ensure your appointment is scheduled or rescheduled promptly and in a manner that guarantees you are properly cared for. Your average appointment waiting time will not exceed one week. Any non-urgent or preventive dental care appointments will always be provided within 30 days of the request. Any emergency or urgent dental needs will be addressed within 72 hours of the request. All Network Dentists’ offices maintain an after-hours telephone recording which will direct you on where and how to receive emergency dental services.
You can always call CDI at anytime at the toll-free number found in Section 1. During normal business-hours, your on-phone wait time will not exceed ten minutes.
Language Assistance and Interpreter Services are also available at request. For more information, please see the Language Assistance Services sheet at the end of this description.
19. Non-Discrimination Policy. CDI has a strict non-discrimination policy that it enforces with all of its Network Dentists and employees. You shall not be discriminated against in any way because of your race, color, national origin, ancestry, religion, disability, sex, marital status, gender, gender identity, sexual orientation, or age. If you feel you been discriminated against in anyway, at any time, please contact CDI through its grievance system, as outlined in Section 15 above, to submit a complaint and CDI will promptly work to resolve the issue. You may also wish to submit a complaint to the United States Department of Health and Human Services Office of Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex. You may submit such a complaint by visiting https://www.hhs.gov/ocr/complaints/index.html.
20. Termination of Network Dentist. CDI’s contract with each Network Dentist specifies that upon termination of the contract the Network Dentist must complete all procedures commenced prior to termination at the discounted rates set forth in Section 11. To request the completion of covered services from a terminated Network Dentist, you may call CDI at the number in Section 1 above and CDI will prompt the terminated Network Dentist to complete all covered procedures at the rates set forth in Section 11. If your Network Dentist does not comply or is unable to complete any procedures, you may call CDI at the number in Section 1 above and CDI will find you an Network Dentist who will complete the procedures.
If your Network Dentist terminates, CDI will promptly notify you if it knows who your Network Dentist is so that you can request the completion of services from the terminated Network Dentist or make arrangements to see another Network Dentist. Also, CDI will post a notice on the website (at https://dentalalliancedentalplan.com) listing all Network Dentists who have given notice of termination, who are being terminated, or who otherwise are unable to provide services. The notice will state the effective date of termination. Also, you can always call CDI at the number in Section 1 above to see whether your dentist is still a Network Dentist.
If CDI 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.
21. If You Have Dental Insurance. Since CDI 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 to see what benefits will be paid.
22. Application of State Law. CDI is subject to the requirements of Chapter 2.2 of Division 2 of the Code and of Chapter 1 of Title 28 of the California Code or Regulations, and any provision required to be in the contract by either of the above shall
bind CDI whether or not provided in this Description.
23. Confidentiality. Each Network Dentist and CDI itself is required by law to keep your personal healthcare information confidential. No such information can be released except with your consent or as expressly authorized by law. A statement describing our policies and procedures for preserving the confidentiality of medical
records is available and will be furnished to you upon request.
24. 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 usually and customarily charges, as determined by the National Dental Advisory Service.
THIS IS ONLY A SUMMARY. YOU SHOULD CONSULT THE FEE SCHEDULE TO DETERMINE THE EXACT FEE FOR ANY PARTICULAR DENTAL SERVICE.
SERVICE CATEGORY - AVERAGE DISCOUNT
Diagnostic - 100%
Preventive - 59%
Restorative - 43%
Endodontics - 49%
Periodontics - 49%
Prosthodontics - (Removable) 45%
Implant Services - N/A
Prosthodontics - (Fixed) 43%
Oral and Maxillofacial Surgery - 39%
Orthodontics - 35%
Adjunctive Services - 28%
California law requires all health care service plans to give members of the public the following information about the applicability of, and any copayments or limitations on, the following:
(A) Deductibles - None
(B) Lifetime Maximums - None
(C) Professional Services - Dental Services Only
(D) Outpatient Services - Not Applicable
(E) Hospitalization Services - Not Applicable
(F) Emergency Health Coverage - Available 24 hours a
day, 7 days a week
(G) Ambulance Services - Not Applicable
(H) Prescription Drug Coverage - Not Applicable
(I) Durable Medical Equipment - Not Applicable
(J) Mental Health Services - Not Applicable
(K) Chemical Dependency Services - Not Applicable
(L) Home Health Services - Not Applicable
(M) Other - Not Applicable
IF YOU COMPLETE AND SUBMIT THE ENROLLMENT FORM, YOU AGREE TO BE BOUND BY ALL OF THE TERMS AND CONDITIONS IN THIS DESCRIPTION.
LANGUAGE ASSISTANCE SERVICES
To all of our discount dental plan enrollees:
CDI maintains a free language assistance program for all enrollees whose preferred language may not be English. Here’s how it works.
If you call a CDI representative or a participating dental office where you are receiving or would like to receive dental services, and if you would like to talk to someone who speaks your preferred language, just ask. You can contact a CDI representative at 1-855-257-2533. If there is a staff member who is fluent in your preferred language and is readily available, the CDI representative or the dental office staff member will quickly put you in touch with that person. If there is no such person who is readily available, the CDI representative will promptly arrange for interpretative services over the telephone if you so desire. You, the CDI or dental office representative, and the interpreter will speak together on a conference call so that all of your questions or requests will be clearly addressed.
The interpretative service CDI uses is AT&T Language Line Services, Inc. Language Line is the preeminent interpretation service in the United States. It can provide interpretation services in all languages, including but not limited to: Arabic, Armenian, Cambodian, Chinese, Farsi, Hindi, Hmong, Japanese, Korean, Punjabi, Russian, Spanish, Tagalog, Thai, and Vietnamese.
If you are actually visiting a participating dental office and need or would prefer assistance in a language other than English, the same procedure will be followed. Upon your request the dental office will first attempt to have you speak with another staff member who speaks your language. If no such staff member is readily available, the dental office will, if you want, immediately arrange for interpretation services through Language Line.
Upon request, appropriate aids and services, including alternative information formats and interpreters for those with disabilities, are available free of charge and will be provided within a timely manner.
Also, if you need any CDI document or written communication translated into Spanish, CDI will provide you with one upon request. Just call CDI at 1-855-257-2533.
Again, none of this costs you anything. CDI wants to make sure all of its enrollees understand its discount dental plan program and the services available under the plan, so we encourage you to use our language assistance services whenever you please.