LIBERTY Dental Plan of Nevada, Inc.
Patriot Plans
Evidence of Coverage
This Evidence of Coverage (EOC) describes the dental care plan
made available to Eligible Employees of the Employer (referred to as
“Group”) and their Eligible Family Members.
LIBERTY Dental Plan of Nevada, Inc. (LIBERTY), and the Group
have agreed to all of the terms of this EOC. It is part of the contract
(Group Enrollment Agreement “GEA”) between LIBERTY and Group.
This plan is guaranteed renewable. This EOC may be terminated by
LIBERTY or the Group upon appropriate written notice in accordance
with the GEA. The Group is responsible for giving Members notice of
termination.
This EOC and your attached Benefit Schedule tell you about your
benefits, rights and duties as a LIBERTY Member. They also tell you
about LIBERTY’s duties to you.
LIBERTY Dental Plan Member Services Department
(888) 401-1128
LIBERTY provides toll-free customer services support Monday
through Friday from 6:00 a.m. through 8:00 p.m. to assist
members.
Members may also log onto our internet site,
www.LIBERTYdentalplan.com, to view plan information, view
claim status, print ID cards, search for Plan Providers, and send
an e-mail notice to our Member Services Department.
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The Department of Business and Industry
State of Nevada
Division of Insurance
Telephone Numbers
for
Consumers of Healthcare
The Division of Insurance (“Division”) has established a telephone
service to receive inquiries and complaints from consumers of
healthcare in Nevada concerning healthcare plans.
The hours of operation of the Division are:
Monday through Friday from 8:00 a.m. until 5:00 p.m., Pacific
Standard Time (PST)
The Division local telephone numbers are:
Carson City (775) 687-4270
Las Vegas (702) 486-4009
The Division also provides a toll-free number for consumers
residing outside of the above areas:
1-(888) 872-3234
All questions about Preexisting Condition Limitation should be
directed to LIBERTY’s Member Services Department:
Address: LIBERTY Dental Plan of Nevada, Inc.
6385 S. Rainbow Blvd., Suite 200
Las Vegas, NV 89118
Phone (Monday Friday from 8:00 a.m. until 5:00 p.m., Pacific
Standard Time):
(888) 401-1128
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Evidence of Coverage
SECTION 1. ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE
Subscribers and Dependents who meet the following criteria are
eligible for coverage under this EOC.
1.1 WHO IS ELIGIBLE
Subscriber. To be eligible to enroll as a Subscriber, an employee
must:
A. Be a bona fide employee of the Group; and
B. meets the following criteria:
Be employed full-time;
Be actively at work;
Work at least the minimum number of hours per week indicated
by the Group in its Application;
Meet the applicable waiting period indicated by the Group in its
Application;
Enroll during an enrollment period;
Live or work in the service area; and
Work for an employer that meets the Minimum Employer
Contribution Percentage for the applicable coverage.
The actively at work requirement will not apply to Individuals covered
under Group’s prior welfare benefit plan on the date of that plan’s
discontinuance, provided that this EOC is initially effective no more
than sixty (60) days after the prior plan’s discontinuance. All other
requirements will apply to such Individuals.
Dependent. To be eligible to enroll as a Dependent, a person must
be one of the following:
A Subscriber's legal spouse or a legal spouse for whom a court
has ordered coverage.
Subscriber's Domestic Partner meeting all of the criteria for a
Qualified Domestic Partnership set forth in LIBERTY's Affidavit of
Domestic Partnership.
An unmarried child by birth. Adopted child. Stepchild. Minor
child for whom a court has ordered coverage. Child being placed
for Adoption with the Subscriber. A child for whom a court has
appointed the Subscriber or the Subscriber’s spouse the legal
guardian.
The child must be under the limiting age of 19 years, and except
in the case of a child for whom a court has ordered coverage, the
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child must qualify as a Dependent of the Subscriber under the
Internal Revenue Code and Regulations.
Any unmarried child, under the age of 23 (or age 24 if your
employer is considered to be a "small employer", 2-50
employees, as defined by Nevada law), who is a full-time student
in an accredited educational institution which is eligible for
payment of benefits under the Veterans Administration Program,
and who is financially dependent on the Subscriber. Proof of full-
time student status must be given to LIBERTY each semester.
Any unmarried child, under the age of 24, who is on a religious
mission and who is financially dependent on the Subscriber. The
religious organization must give LIBERTY a letter, which states
the Dependent is on a religious mission. Proof of the continuation
of the religious mission status must be given to LIBERTY at least
twice a year.
Any unmarried child who is incapable of self-sustaining
employment due to mental or physical handicap, chiefly
dependent upon the Subscriber for economic support and
maintenance, and who has satisfied all of the requirements of (a)
or (b) below.
(a) The child must be a Dependent enrolled under this EOC
before reaching the limiting age, and proof of incapacity and
dependency must be given to LIBERTY by the Subscriber
within thirty-one (31) days of the child reaching the limiting
age; or
(b) The handicap started before the child reached the limiting
age, but the Group was enrolled with another health
insurance carrier that covered the child as a handicapped
Dependent prior to the Group enrolling with LIBERTY.
LIBERTY may require proof of continuing incapacity and dependency,
but not more often than once a year after the first two (2) years
beyond when the child reaches the limiting age. LIBERTY’s
determination of eligibility is final.
Evidence of any court order needed to prove eligibility must be given
to LIBERTY.
Group’s eligibility rules may supersede the Dependent guidelines
noted above. Please contact the sponsor of this program to
determine eligibility requirements.
1.2 WHO IS NOT ELIGIBLE
Eligible Dependents do not include:
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A foster child.
A child placed in the Subscriber's home other than for the
purpose of adoption.
A grandchild other than a grandchild that has been adopted by
the grandparents and/or has not been place in the home of the
grandparents for the purposes of adoption.
Any other person not defined in Section 1.1.
1.3 CHANGES IN ELIGIBILITY STATUS
It is the Subscriber's responsibility to give LIBERTY written notice
within thirty-one (31) days of changes, which affect his Dependents’
eligibility. Changes include:
Reaching the limiting age.
Death.
Divorce.
Marriage.
Termination of a Domestic Partnership that qualifies for coverage
under LIBERTY's Affidavit of Domestic Partnership.
Or transfer of residence or work outside LIBERTY’s Service Area.
If Subscriber fails to give notice, which would have resulted in
termination of coverage, LIBERTY shall have the right to terminate
coverage retroactively.
1.4 ENROLLMENT
Eligible Employees and Eligible Family Members must enroll during
one of the Enrollment Periods described below or within thirty-one
(31) days of first becoming eligible in order to have coverage under
this Plan.
1. Initial Enrollment Period. An Initial Enrollment Period is the
period of time during which an Eligible Employee may enroll
under this Plan, as shown in the GEA signed by the Group.
2. Group Open Enrollment Period. An Open Enrollment Period of
at least thirty-one (31) days may be held at least once a year
allowing Eligible Employees and Eligible Family Members to
enroll under this Plan without giving evidence of good health.
3. Special Enrollment Period. A Special Enrollment Period allows
a Special Enrollee to enroll for coverage under this Plan upon a
Special Enrollment Event as defined herein during a period of at
least thirty-one (31) days following the Special Enrollment Event.
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4. Right to Deny Application. LIBERTY can deny membership to
any person who:
Violates or has violated any provision of a LIBERTY EOC.
Misrepresents or fails to disclose a material fact which would
affect coverage under this Plan.
Fails to follow LIBERTY rules.
Fails to make a premium payment.
5. Right to Deny Application for Renewal. As a condition of
Group’s renewal under this Plan, LIBERTY may require Group to
exclude a Subscriber or Dependent who committed fraud upon
LIBERTY or misrepresented and/or failed to disclose a material
fact, which affected his coverage under this Plan.
1.5 EFFECTIVE DATE OF COVERAGE
Before coverage can become effective, LIBERTY must receive and
accept premium payments and an Enrollment Form for the person
applying to be a Member.
When a person applies to be a Member on or before the date he is
eligible, coverage starts as shown in the GEA signed by Group.
1. If a person applies to be a Member within thirty-one (31) days of
the date he is first eligible to apply, coverage starts on the first
day of the calendar month following the month when the
Enrollment Form is received by LIBERTY.
2. Subscriber's newborn natural child is covered for the first thirty-
one (31) days from birth. Coverage continues after thirty-one
(31) days only if the Subscriber enrolls the child as a Dependent
the premium is paid within thirty-one (31) days of the date of
birth.
3. An adopted child is covered for the first thirty-one (31) days from
birth only if the adoption has been legally completed before the
child’s birth. A child Placed for Adoption at any other age is
covered for the first thirty-one (31) days after the placement for
adoption.
Coverage continues after thirty-one (31) days only if the
Subscriber enrolls the child as a Dependent and the premium is
paid within thirty-one (31) days following the placement of the
child in the Subscriber’s home. In the event adoption
proceedings are terminated, coverage of a child Placed for
Adoption ends on the date the adoption proceedings are
terminated.
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4. If a court has ordered Subscriber to cover his or her legal spouse
or unmarried minor child, that person will be covered for the first
thirty-one (31) days following the date of the court order.
Coverage continues after thirty-one (31) days if the Subscriber
enrolls the Dependent and the Dependent’s premium is paid. A
copy of the court order must be given to LIBERTY.
5. For a Special Enrollee, the Effective Date of coverage is as
follows:
In the case of marriage, on the first day of the calendar month
after the marriage date; or
In the case of birth, adoption or Placement for Adoption, upon
the Dependent’s date of birth, or upon the Dependent’s date
of adoption or Placement for Adoption; or
In the case of all other Special Enrollment Events, on the first
day of the calendar month after an Enrollment Form is
received, unless otherwise specified in the GEA.
6. When a person applies to be a Member during the Open
Enrollment Period, coverage starts on the first day of the
calendar month following the Open Enrollment Period.
Subscriber must give LIBERTY a copy of the certified birth
certificate, decree of adoption, or certificate of placement for
adoption for coverage to continue after thirty-one (31) days for
newborn and adopted children.
Subscriber must give LIBERTY a copy of the certified marriage
certificate, complete affidavit of domestic partnership (LIBERTY's
form only), proof of student status or any other required
documents before coverage can be effective for other Eligible
Family Members.
SECTION 2. TERMINATION
LIBERTY may terminate coverage under this Plan at the times shown
for any one or more of the following reasons:
2.1 TERMINATION BY LIBERTY
Failure to maintain eligibility requirements as set forth in Section
1.
Payment is due on the day of each month that you are insured by
LIBERTY. There is a 30 day grace period for payment to be
received by LIBERTY. The member will be terminated on the 31
st
day if payment has not been received by LIBERTY.
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On the first day of the month that a contribution was due and not
received by LIBERTY.
With thirty (30) days written notice, if the Member allows his or
any other Member's LIBERTY ID card to be used by any other
person, or uses another person's card. The Member will be liable
to LIBERTY for all costs incurred as a result of the misuse of the
LIBERTY Member card.
If information given to LIBERTY by the Member in his Enrollment
Form is untrue, inaccurate, or incomplete, LIBERTY has the right
to declare the coverage under the Plan null and void as of the
original Effective Date of coverage if the discovery is made within
two years of the document being received by LIBERTY.
When a Subscriber moves his primary residence outside the
Service Area and/or no longer has his place of work within the
Service Area or when a Dependent moves his primary residence
outside LIBERTY's Service Area, Subscriber must notify
LIBERTY within thirty-one (31) days of the change. LIBERTY will
request proof of the change of residence and/or place of work.
On the date the GEA terminates for any reason, including but not
limited to:
1. Nonpayment of premiums.
2. Failure to meet minimum enrollment requirements.
3. LIBERTY amends this EOC and the Group does not accept
the amendment.
2.2 TERMINATION BY THE SUBSCRIBER
Subscriber has the right to terminate his coverage under the Plan.
Termination notice must be reported to LIBERTY by the sponsor of
this program. Such termination is effective on the last day of the
month when the notice is received by LIBERTY, unless stated
otherwise in the GEA.
2.3 REINSTATEMENT
Any coverage which has been terminated in any manner, may be
reinstated by LIBERTY at its sole discretion.
2.4 Retroactive Termination
A request for retroactive termination by Group may be granted as
shown in the GEA.
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2.5 EFFECT OF TERMINATION
No benefits will be paid under this Plan by LIBERTY for services
provided after termination of a Member's coverage under this Plan.
You will be responsible for payment of all services and supplies
incurred after the effective date of the termination of this EOC and/or
the GEA.
SECTION 3. USING THIS PLAN
This Plan offers you a choice of where you receive your dental care.
However, to receive Tier 1 benefits under this plan, you must receive
care from a Plan Provider. When you choose to receive your care
from any dentist that is a Plan Provider, your costs will be limited by
the costs identified in the first column (Member Co-Pay) Schedule of
Benefits. You will also not need to submit any claim forms when you
receive your care from a Plan Provider. To receive benefits for care
provided by a Specialist your Plan Provider must initiate the referral
process with LIBERTY. LIBERTY will then refer you to a Specialist
who is a Plan Specialty Provider for approved Specialty services.
Care by a Specialist that was not approved by LIBERTY following the
Specialty Referral process noted above will not be considered a
covered benefit.
You and your dependents can choose a Plan Provider from a network
of private practice dental offices. A list of Plan Providers is available
through the Plan.
If you wish to receive care from a non-Plan Provider, the 2
nd
column
(Plan Pays) in the Schedule of Benefits identifies the amount the Plan
will pay for services. You will be responsible to pay any amount over
the Plan Payment. There is an annual deductible and an annual
maximum amount payable by the Plan associated with Tier 2
benefits.
SECTION 4. COVERED SERVICES
This section tells you what services are covered under this Plan.
Only services and supplies, which meet LIBERTY’s definition of
Dentally Necessary and are identified as covered benefits on the
Benefits Schedule will be considered to be Covered Services. The
Benefit Schedule shows applicable Copayments and benefit
limitations for Covered Services.
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4.1 BENEFITS AVAILABLE
Subject to the Exclusions listed herein, dental services related to a
Member's dental health as identified in the Benefits Schedule and that
are dentally necessary are available to Members.
Tier 1 Benefits must be obtained from Plan Providers. The Benefit
Schedule identifies the member copayments that are to be paid to
Plan Providers at the time of service. Tier 2 Benefits may be obtained
from any licensed dentist. The Benefit Schedule identifies the Plan
Pays amount and you will be responsible to pay the non-Plan
Provider any amount charged over the Play Pays amount.
4.2 CLAIM PAYMENTS
Plan Providers are paid an amount agreed upon between the Plan
and the Plan Provider plus any copayment from the Member required
by the Benefit Schedule.
All claims shall be approved or denied within thirty (30) days after
receipt by the Plan, unless additional information is requested. If the
claim is approved, the claim will be paid within thirty (30) days after it
is approved. If the Plan requires additional information, the Member
shall be notified within twenty (20) days after the Plan actually
receives the claim. The claim will be paid or denied within thirty (30)
days of the Plan's receipt of all of the additional information it
requested.
All claims must be submitted to LIBERTY within sixty (60) days from
the date expenses were incurred, unless it shall be shown not to have
been reasonably possible to give notice within the time limit, and that
notice was furnished as