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

 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

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

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.

NV_Patriot_01/10 - 10 -

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 soon as was reasonably possible.

No payments shall be made under this EOC with respect to any

claim, including additions or corrections to a claim which has already

been submitted, that is not received by LIBERTY within twelve (12)

months after the date Covered Services were provided.

Denials of claims can be submitted to the Plan's Grievance

procedures described in this EOC.

4.3 EMERGENCY SERVICES

In the event of an emergency outside the service area of the Plan, the

Member should contact LIBERTY at (888) 401-1128 The Plan will

direct you to an available Plan Provider if possible. Should no Plan

Provider be available in a fifty (50) mile radius you can seek treatment

NV_Patriot_01/10 - 11 -

from any licensed dentist. In such an event, the Plan will reimburse

you for the cost of qualified emergency services received from an out-

of-network provider up to a maximum of seventy-five dollars ($75),

less any applicable member co-payments based on the Plan Benefits.

Any non-qualified emergency services will not be considered as

reimbursable emergency services.

The Plan provides coverage for emergency dental services only if the

services are required to alleviate severe pain or bleeding or if an

enrollee reasonably believes that the condition, if not diagnosed or

treated, may lead to disability, dysfunction or death.

Qualified emergency dental service and care include a dental

screening, examination, evaluation by a dentist or dental specialist to

determine if an emergency dental condition exists, and to provide

care that would be acknowledged as within professionally recognized

standards of care an in order to alleviate any emergency symptoms in

a dental office.

SECTION 5. EXCLUSIONS AND LIMITATIONS

5.1 EXCLUSIONS

In addition to items identified as NOT COVERED in the Benefits

Schedule, this section tells you what services or supplies are

excluded from coverage under this Plan.

 Dental services for aesthetics only and/or cosmetic dental

care unless otherwise listed as a covered benefit.

 General anesthesia, intravenous and inhalation sedation,

prescription drugs for anesthesia, and the services of a

special anesthesiologist unless otherwise listed as a covered

benefit.

 Dental conditions arising out of and due to a Member's

employment or for which the Member is entitled to Workers'

Compensation benefits.

 Hospital and medical facility charges of any kind.

 Services of any kind provided in the home.

 Ambulance services.

 Durable Medical Equipment.

 Mental Health services.

 Chemical Dependency services

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 General anesthesia, analgesia, intravenous/intramuscular

sedation or the services of an anesthesiologist unless

otherwise listed as a Covered Benefit.

 Treatment started before the member was eligible, or after

the member was no longer eligible.

 Charges from a medical doctor, doctor of osteopathic

medicine and/or other medical professional except for dental

services otherwise covered herein.

 Treatment of fractures or dislocations.

 Replacement of lost or stolen dentures, partials or other

appliances (e.g. crowns, bridges, full or partial dentures).

 Services which are normally reimbursed by a third party or

liability insurance and/or under the medical portion of a group

health plan.

 Dental procedures for which treatment was started prior to

the time Member became eligible for benefits.

 Procedures, appliances, restorations or other treatment to

correct congenital or developmental malformations.

 Treatment and/or removal of: (a) malignancies; (b) cysts or

benign tumors not within the scope of usual dental care; (c)

odontongenic cysts exceeding 1.25 cm in diameter.

 Drugs/ medications not normally supplied or prescribed by a

dental office.

 Any treatment which, on the opinion of LIBERTY's Dental

Director, is not necessary for the Member's dental health.

 Replacement of an existing bridge, partial or denture which,

in the opinion of LIBERTY's Dental Director, is satisfactory or

that can be made satisfactory.

 Orthognathic surgery.

 Implants or any prosthesis attached to or dependent upon an

implant unless otherwise listed as a covered benefit on the

Benefits Schedule.

 Any experimental, investigational or exotic procedure not

approved by the ADA Council on Dental Therapeutics.

 Treatment to alter vertical dimension or to restore occlusion,

unless dentures are involved.

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 Treatment or therapy for Temporo Mandibular Joint (TMJ)

problems including, but not limited to, assessment beyond

that customarily provided in a general dental practice.

 Procedures, appliances, or restorations to correct congenital,

developmental or medically induced dental disorder, including

but not limited to: myofunctional (e.g. speech therapy),

myoskeletal, or temporomandibular joint dysfunctions (e.g.

adjustments/corrections to the facial bones) unless otherwise

covered as an orthodontic benefit.

 Appliances needed to increase vertical dimension or restore

occlusion.

 Crowns for the primary purpose of splinting, altering, or

maintaining vertical dimension or restoring occlusion.

 Treatment or service which may not reasonably be expected

to successfully correct the patient’s dental condition for a

period of at least three years.

 Treatment or service replacing tooth structure lost from

abrasion, attrition, erosion, or abfraction.

 Expense or charge incurred by a Member confined to an

institution of any kind.

 Cases in which, in the reasonable professional judgment

LIBERTY's Dental Director, a satisfactory result cannot be

obtained.

 Replacement of long-standing missing tooth/teeth in an

otherwise stable dentition.

 Orthodontic services unless otherwise listed as a covered

benefit.

 Care related to the bite, alignment of teeth, or bite correction.

 Charges for specialized techniques involving precision

attachments, personalization or characterization of a

temporary or permanent prosthesis.

 Any service not specifically listed as a Covered Benefit on the

Benefits Schedule.

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5.2 LIMITATIONS

In addition to the limitations of coverage identified in the Benefits

Schedule, this section tells you when LIBERTY's duty to provide or

arrange for services is limited.

 LIBERTY will not be liable for any delay or failure to provide

or arrange for Covered Services if the delay or failure is

caused by the following:

- Natural disaster.

- War.

- Riot.

- Civil insurrection.

- Epidemic.

- Or any other emergency beyond LIBERTY’s

control.

 Prophylaxis is limited to one treatment each (6) month period

(includes periodontal maintenance following active therapy).

 Oral evaluation is limited to two in each (12) month period.

 Oral hygiene instruction is limited to one per twenty-four (24)

month period.

 Fluoride treatment is limited to one treatment every six (6)

month period.

 Crowns, bridges and dentures may not be replaced within five

(5) years from the initial placement.

 Partial dentures are not to be replaced within five (5) years of

the initial placement, unless necessary due to natural tooth

loss where the addition or replacement of teeth to the existing

partial is not feasible.

 Denture relines are limited to one per denture during any

twelve (12) consecutive months.

 Covered charge for both a temporary and a permanent

prosthesis will be limited to the charge for a permanent

prosthesis only.

 Charges for adjustment of a prosthesis will be limited to one

in a six (6) month period.

 Periodontal treatments are limited to one time per quadrant

during any twenty-four (24) consecutive months.

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 Fill mouth debridement (gross scale) is limited to one

treatment in any thirty-six (36) consecutive month period.

 Osseous surgery is limited to one treatment in any five (5)

year period.

 Crowns will be covered only if, in the opinion of LIBERTY's

Dental Director, there is not enough retentive quality left in

the tooth to hold a filing.

 Bitewing x-rays are limited to not more than one series of four

films in any six (6) month period.

 Full mouth x-rays and/or panographic-type films are limited to

one set every thirty-six (36) consecutive months.

 Sealant benefits include the application of sealants only to

permanent first and second molars with no decay for

dependent children only up to the age of 14. Sealant benefits

limited to once per tooth in any 36 consecutive month period.

 Periodontal scaling and root planning limited to once each

quadrant in any 24 consecutive month period.

 Periodontal surgical procedures are limited to once per

quadrant in any 36 consecutive month period.

 Crowns are covered only if the tooth cannot be restored by a

filling.

 If LIBERTY determines that more than one procedure could

be performed to correct a dental condition, the covered

benefit will be the least expensive of the procedures that

would provide professionally acceptable results.

SECTION 6. GENERAL PROVISIONS

6.1 RELATIONSHIP OF PARTIES

The relationship between LIBERTY and Plan Providers is an

independent contractor relationship. Plan Providers are not agents or

employees of LIBERTY; nor is LIBERTY or any employee of

LIBERTY an employee or agent of a Plan Provider. LIBERTY is not

liable for any claim or demand on account of damages as a result of,

or in any manner connected with, any Injury suffered by a Member

while receiving care from any Plan Provider or in any Plan Provider's

facility. LIBERTY is not bound by statements or promises made by its

Plan Providers.

NV_Patriot_01/10 - 16 -

6.2 ENTIRE AGREEMENT

This EOC along with the Group Enrollment Agreement, Enrollment

Forms/Application constitute the entire agreement between the

Member and LIBERTY and as of its Effective Date, replaces all other

agreements between the parties.

6.3 CONTESTABILITY

Any and all statements made to LIBERTY by Group and any

Subscriber or Dependent, will, in the absence of fraud, be considered

representations and not warranties. Also, no statement, unless it is

contained in a written application for coverage, shall be used in

defense to a claim under this agreement.

6.4 AUTHORITY TO CHANGE THE FORM OR

CONTENT OF EOC

No agent or employee of LIBERTY is authorized to change the

agreement or waive any of its provisions. Such changes can be

made only through an amendment authorized and signed by an

officer of LIBERTY.

6.5 IDENTIFICATION CARD

Cards issued by LIBERTY to Members are for identification only.

Possession of the LIBERTY identification card does not give right to

services or other benefits under this Plan.

To be entitled to such services or benefits, the holder of the card must

in fact be a Member and all applicable premiums actually have been

paid. Any person not entitled to receive services or other benefits will

be liable for the actual cost of such services or benefits.

6.6 NOTICE

Any notice under this Plan may be given by United States mail, first

class, postage paid, addressed as follows:

LIBERTY Dental Plan of Nevada, Inc.

6385 S. Rainbow Blvd., Suite 200

Las Vegas, NV 89118

Notice to a Member will be sent to the Member's last known address.

6.7 ASSIGNMENT

This EOC is not assignable by Group without the written consent of

LIBERTY. The coverage and any benefits under this Plan are not

assignable by any Member without the written consent of LIBERTY.

NV_Patriot_01/10 - 17 -

6.8 MODIFICATIONS

The Group makes LIBERTY coverage available to individuals who

are eligible under Section 1. However, this EOC is subject to

amendment, modification and termination with sixty (60) days written

notice to the Group without the consent of Members.

By electing dental coverage with LIBERTY or accepting benefits

under this Plan, all Members legally capable of contracting, and the

legal representatives of all Members incapable of contracting, agree

to all terms and provisions.

6.9 CLERICAL ERROR

Clerical error in keeping any record pertaining to the coverage will not

invalidate coverage in force or continue coverage terminated.

6.10 POLICIES AND PROCEDURES

LIBERTY may adopt reasonable policies, procedures, rules and

interpretations to promote the orderly and efficient administration of

this EOC with which Members shall comply. These policies and

procedures are maintained by LIBERTY at its offices. Such policies

and procedures may have bearing on whether dental service and/or

supply are covered.

6.11 OVERPAYMENTS

LIBERTY has the right to collect payments for healthcare services

made in error. Dentists, Specialists and other providers have the

responsibility to return any overpayments or incorrect payments to

LIBERTY. LIBERTY has the right to offset any overpayment against

any future payments.

6.12 RELEASE OF RECORDS

Each Member authorizes their providers to permit the examination

and copying of the Member's medical records, as requested by

LIBERTY.

6.13 GENDER REFERENCES

Whenever a masculine pronoun is used in this EOC, it also includes

the feminine pronoun.

6.14 AVAILABILITY OF PROVIDERS

LIBERTY does not guarantee the continued availability of any Plan

Provider.

SECTION 7. APPEALS AND GRIEVANCES

The LIBERTY Appeals Procedures are available to you in the event

you are dissatisfied with some aspect of the Plan administration, you

NV_Patriot_01/10 - 18 -

wish to appeal an Adverse Benefit Determination or there is another

concern you wish to bring to LIBERTY's attention. This procedure

does not apply to any problem of misunderstanding or misinformation

that can be promptly resolved by the Plan supplying the Member with

the appropriate information.

If a Member’s Plan is governed by ERISA, a Member must exhaust all

mandatory levels of appeal before bringing a claim in court for a

Claim of Benefits.

Concerns about dental services are best handled at the service site

level before being brought to LIBERTY. If a Member contacts

LIBERTY regarding an issue related to the dental service site and has

not attempted to work with the site staff, the Member may be directed

to that site to try to solve the problem there, if the issue is not a Claim

for Benefits.

Please see the Glossary terms for a description of the terms used in

this section.

The following Appeals Procedures will be followed if the dental

service site matter cannot be resolved at the site or if the concern

involves the Adverse Benefit Determination of a Claim for Benefits.

 Informal Review: An Adverse Benefit Determination or other

complaint/concern which is directed to the LIBERTY Member

Services Department via phone or in person. If an Informal

Review is resolved to the satisfaction of the Member, the matter

ends. The Informal Review is voluntary.

 1

Level Formal Appeal: An appeal of an Adverse Benefit

Determination filed either orally or in writing which LIBERTY’s

Customer Response and Resolution Department investigates. If

a 1

Level Formal Appeal is resolved to the satisfaction of the

Member, the appeal is closed. The 1

Level Formal Appeal is

mandatory if the Member is not satisfied with the initial

determination and the Member wishes to appeal such

determination.

 2

Level Formal Appeal: If a 1

Level Formal Appeal is not

resolved to the Member’s satisfaction, a Member may then file a

Level Formal Appeal. A 2

Level Formal Appeal is submitted

in writing and reviewed by the Grievance Review Committee.

The 2

Level Formal Appeal is voluntary for all Adverse Benefit

Determinations.

NV_Patriot_01/10 - 19 -

 Grievance Review Committee: A committee of three (3) or

more individuals, the majority of which must be Members of

LIBERTY.

 Member Services Representative: An employee of LIBERTY

that is assigned to assist the Member or the Member's authorized

representative in filing a grievance with LIBERTY or appealing an

Adverse Benefit Determination.

7.1 INFORMAL REVIEW

A Member who has received an Adverse Benefit Determination of a

Claim for Benefits may request an Informal Review. All Informal

Reviews must be made to LIBERTY’s Member Services Department

within sixty (60) days of the Adverse Benefit Determination. Informal

Reviews not filed in a timely manner will be deemed waived. The

Informal Review is a voluntary level of appeal.

Upon the initiation of an Informal Review, a Member must provide

Member Services with at least the following information:

 The Member’s name (or name of Member and Member’s

Authorized Representative), address, and telephone number;

 The Member’s LIBERTY membership number and Group name;

and

 A brief statement of the nature of the matter, the reason(s) for the

appeal, and why the Member feels that the Adverse Benefit

Determination was wrong.

The Member Services Representative will inform the Member that

upon review and investigation of the relevant information, LIBERTY

will make a determination of the Informal Review. The determination

will be made as soon as reasonably possible but will not exceed thirty

(30) days unless more time is required for fact-finding. If the

determination of the Informal Review is not acceptable to the Member

and the Member wishes to pursue the matter further, the Member

may file a 1

Level Formal Appeal.

7.2 FIRST LEVEL FORMAL APPEAL

When an Informal Review is not resolved in a manner that is

satisfactory to the Member or when the Member chooses not to file an

Informal Review and the Member wishes to pursue the matter further,

the Member must file a 1

Level Formal Appeal. The 1

Level Formal

Appeal must be submitted in writing to LIBERTY’s Customer

Response and Resolution Department within 180 days of an Adverse

NV_Patriot_01/10 - 20 -

Benefit Determination. 1

Level Formal Appeals not filed in a timely

manner will be deemed waived with respect to the Adverse Benefit

Determination to which they relate.

The 1

Level Formal Appeal shall contain at least the following

information:

 The Member’s name (or name of Member and Member’s

Authorized Representative), address, and telephone number;

 The Member’s LIBERTY membership number and Group name;

and

 A brief statement of the nature of the matter, the reason(s) for

the appeal, and why the Member feels that the Adverse Benefit

Determination was wrong.

Additionally, the Member may submit any supporting medical/dental

records, Dentist’s letters, or other information that explains why

LIBERTY should approve the Claim for Benefits. The Member can

request the assistance of a Member Services Representative at any

time during this process.

The 1

Level Formal Appeals should be sent or faxed to the following:

Address: LIBERTY Dental Plan of Nevada, Inc.

Attn: Customer Response and Resolution Dept.

6385 S. Rainbow Blvd., Suite 200

Las Vegas, NV 89118

Fax: (888) 401-1129

LIBERTY will investigate the appeal. When the investigation is

complete, the Member will be informed in writing of the resolution

within thirty (30) days of receipt of the request for the 1

Level Formal

Appeal. This period may be extended one (1) time by LIBERTY for up

to fifteen (15) days, provided that the extension is necessary due to

matters beyond the control of LIBERTY and LIBERTY notifies the

Member prior to the expiration of the initial thirty (30) day period of the

circumstances requiring the extension and the date by which

LIBERTY expects to render a decision. If the extension is necessary

due to a failure of the Member to submit the information necessary to

decide the claim, the notice of extension shall specifically describe

the required information and the Member shall be afforded at least

forty-five (45) days from receipt of the notice to provide the

information.

Level Formal Appeals will be decided by a Grievance Review

Committee.

NV_Patriot_01/10 - 21 -

If the 1

Level Formal Appeal results in an Adverse Benefit

Determination, the Member will be informed in writing of the following:

 The specific reason or reasons for upholding the Adverse Benefit

Determination;

 Reference to the specific Plan provisions on which the

determination is based;

 A statement that the Member is entitled to receive, upon request

and free of charge, reasonable access to, and copies of, all

documents, records, and other information relevant to the

Member’s Claim for Benefits;

 A statement describing any voluntary appeal procedures offered

by LIBERTY and the Member’s right to receive additional

information describing such procedures;

 For Member’s whose coverage is subject to ERISA, a statement

of the Member’s right to bring a civil action under ERISA Section

502(a) following an Adverse Benefit Determination, if applicable;

 A statement that any internal rule, guideline, protocol or other

similar criteria that was relied on in making the determination is

available free of charge upon the Member’s request; and

 If the Adverse Benefit Determination is based on Medical

Necessity or experimental treatment or similar exclusion or limit,

either an explanation of the scientific or clinical judgment or a

statement that such explanation will be provided free of charge.

Limited extensions may be required if additional information is

required in order for LIBERTY to reach a resolution.

If the resolution to the 1

Level Formal Appeal is not acceptable to

the Member and the Member wishes to pursue the matter further, the

Member is entitled to file a 2

Level Formal Appeal. The Member will

be informed of this right at the time the Member is informed of the

resolution of his 1

Level Formal Appeal.

7.3 EXPEDITED APPEAL

The Member can ask (either orally or in writing) for an Expedited

Appeal of an Adverse Benefit Determination for a Pre-Service Claim

that the Member or his Dentist believe that the health of the Member

could be seriously harmed by waiting for a routine appeal decision.

Expedited Appeals are not available for appeals regarding denied

claims for benefit payment (Post-Service Claim). Expedited Appeals

must be decided no later than seventy-two (72) hours after receipt of

the appeal, provided all necessary information has been submitted to

LIBERTY. If the initial notification was oral, LIBERTY shall provide a

NV_Patriot_01/10 - 22 -

written or electronic explanation to the Member within three (3) days

of the oral notification.

If insufficient information is received, LIBERTY shall notify the

Member as soon as possible, but no later than twenty-four (24) hours

after receipt of the claim of the specific information necessary to

complete the claim. The Member will be afforded a reasonable

amount of time, taking into account the circumstances, but not less

than forty-eight (48) hours, to provide the specified information.

LIBERTY shall notify the Member of the benefit determination as

soon as possible, but in no case later than forty-eight (48) hours after

the earlier of:

 LIBERTY’s receipt of the specified information, or

 The end of the period afforded the Member to provide the

specified information.

If the Member’s Dentist requests an Expedited Appeal, or supports a

Member’s request for an Expedited Appeal, and indicates that waiting

for a routine appeal could seriously harm the health of the Member or

subject the Member to unmanageable severe pain that cannot be

adequately managed without care or treatment that is the subject of

the Claim for Benefits, LIBERTY will automatically grant an Expedited

Appeal.

If a request for an Expedited Appeal is submitted without support of

the Member’s Dentist, LIBERTY shall decide whether the Member’s

health requires an Expedited Appeal. If an Expedited Appeal is not

granted, LIBERTY will provide a decision within thirty (30) days,

subject to the routine appeals process for Pre-Service Claims.

7.4 SECOND LEVEL FORMAL APPEAL

When a 1

Level Formal Appeal is not resolved in a manner that is

satisfactory to the Member, the Member may initiate a 2

Level

Formal Appeal. This appeal must be submitted in writing within thirty

(30) days after the Member has been informed of the resolution of the

Level Formal Appeal.

Exhaustion of the 1

Level Formal Appeal procedure is a precondition

to filling a 2

Level Formal Appeal. A 2

Level Formal Appeal not

filed in a timely manner will be deemed waived with respect to the

Adverse Benefit Determination to which it relates. The 2

Level

Formal Appeal is voluntary for all Pre-Service and Post-Service

Claims for Benefits.

NV_Patriot_01/10 - 23 -

The Member shall be entitled to the same reasonable access to

copies of documents referenced above under the 1

Level Formal

Appeal.

The Member can request the assistance of a Member Services

Representative at any time during this process.

Upon request a Member is entitled to attend and provide a formal

presentation on a 2

Level Formal Appeal. If such a hearing is

requested LIBERTY shall make every reasonable effort to schedule

one at a time mutually convenient to the parties involved. Repeated

refusal on the part of the Member to cooperate in the scheduling of

the formal presentation shall relieve the Grievance Review Committee

of the responsibility of hearing a formal presentation, but not of

reviewing the 2

Level Formal Appeal. If a formal presentation is

held, the Member will be permitted to provide documents to the

Grievance Review Committee and to have assistance in presenting

the matter to the Grievance Review Committee, including

representation by counsel. However, LIBERTY must be notified at

least five (5) business days before the date of the scheduled formal

presentation of the Member’s intent to be represented by counsel

and/or to have others present during the formal presentation.

Additionally, the Member must provide LIBERTY with copies of all

documents the Member may use at the formal presentation (5)

business days before the date of the scheduled formal presentation.

Upon LIBERTY’s receipt of the written request, the request will be

forwarded to the Grievance Review Committee along with all

available documentation relating to the appeal.

The Grievance Review Committee shall:

 consider the 2

Level of Appeal;

 schedule and conduct a formal presentation if applicable;

 obtain additional information from the Member and/or staff as it

deems appropriate; and

 make a decision and communicate its decision to the Member

within thirty (30) days following LIBERTY’s receipt of the request

for a 2

Level Formal Appeal.

If the resolution of the 2

Level Formal Appeal results in an Adverse

Benefit Determination, the Member will be informed in writing of the

following:

NV_Patriot_01/10 - 24 -

 The specific reason or reasons for upholding the Adverse Benefit

Determination;

 Reference to the specific Plan provisions on which the benefit

determination is based;

 A statement describing any additional voluntary levels of appeal;

and

 For Member’s whose coverage is subject to ERISA, a statement

of the Member’s right to bring a civil action under ERISA Section

502(a) following an Adverse Benefit Determination, if applicable;

Limited extensions may be required if additional information is

required or a formal presentation is requested and the Member

agrees to the extension of time.

7.5 EXTERNAL REVIEW

LIBERTY offers Members the right to an External Review of a final

Adverse Benefit Determination when a Member or the Member’s

Dentist receives notice of a final Adverse Benefit Determination from

LIBERTY, and when the Member is required to pay $500 or more for

healthcare services that are the subject of the final Adverse Benefit

Determination. A Member is entitled to an External Review only after

the Member has exhausted all procedures provided in this plan for

reviewing the Adverse Benefit Determination or if LIBERTY agrees in

writing to submit the matter to External Review before the Member has

exhausted all procedures provided in this plan for reviewing the

Adverse Benefit Determination. The Member, Member’s Dentist, or an

Authorized Representative may within sixty (60) days after receiving

notice of such final Adverse Benefit Determination, submit a request to

LIBERTY’s Managed Care Program for an External Review.

Within five (5) days after LIBERTY receives such a request, LIBERTY

shall notify the Member, his Authorized Representative or Dentist, and

the Nevada Office for Consumer Health Assistance that the request

has been received and filed.

The Nevada Office for Consumer Health Assistance shall assign an

External Review Organization to review the case.

Within five (5) days after receiving notification specifying the assigned

External Review Organization from the Nevada Office for Consumer

Health, LIBERTY shall provide to the selected External Review

Organization all documents and materials relating to the final Adverse

Benefit Determination, including, without limitation:

NV_Patriot_01/10 - 25 -

 Any medical records of the Member relating to the final Adverse

Benefit Determination;

 A copy of the provisions of the Plan upon which the final Adverse

Benefit Determination was based;

 Any documents used and the reason(s) given by LIBERTY for the

final Adverse Benefit Determination; and

 If applicable, a list that specifies each Provider who provided

healthcare to the Member and the corresponding medical records

from the Provider relating to the final Adverse Benefit

Determination.

Within five (5) days after the External Review Organization receives the

required documentation from LIBERTY, they shall notify the Member,

his Dentist, and LIBERTY if any additional information is required to

conduct the review.

The External Review Organization shall approve, modify, or reverse the

final Adverse Benefit Determination within fifteen (15) days after it

receives the information required to make such a determination.

The External Review Organization shall submit a copy of its

determination, including the basis thereof, to the:

 Member;

 Member’s Dentist;

 Authorized Representative of the Member, if any; and

 LIBERTY.

If the determination of an External Review Organization concerning an

External Review of a final Adverse Benefit Determination is in favor of

the Member, the determination is final, conclusive and binding.

The cost of conducting an External Review of a final Adverse Benefit

Determination will be paid by LIBERTY.

7.6 EXPEDITED EXTERNAL REVIEW

If the Member’s healthcare Provider submits proof to LIBERTY that

failure to proceed in an expedited manner may jeopardize the life or

health of the Member, then LIBERTY shall approve or deny a request

for an expedited External Review of an Adverse Benefit Determination

no later than seventy-two (72) hours after the request for an expedited

External Review is received.

NV_Patriot_01/10 - 26 -

If LIBERTY approves the expedited External Review, LIBERTY shall

assign the request to an External Review Organization no later than

one (1) business day after approving the request. All relevant medical

documents previously listed herein that were used to establish the final

Adverse Benefit Determination will be forwarded to the External Review

Organization concurrently.

The External Review Organization shall complete its External Review

no later than two (2) business days after initially being assigned the

case unless the Member and LIBERTY agree to a longer time period.

The External Review Organization shall notify the following parties by

telephone no later than one (1) business day after completing its

External Review:

 Member;

 Member’s Dentist;

 Authorized Representative of the Member, if any; and

 LIBERTY.

The External Review Organization shall then submit a written copy of

its determination no later than five (5) business days to the applicable

parties listed above.

If the determination of an External Review Organization concerning an

External Review of a final Adverse Benefit Determination is in favor of

the Member, the determination is final, conclusive and binding.

The cost of conducting an External Review of a final Adverse Benefit

Determination will be paid by LIBERTY.

SECTION 8. GLOSSARY

“Adverse Benefit Determination” means a decision by the Plan to

deny, in whole or in part, a Member’s Claim for Benefits. Receipt of

an Adverse Benefit Determination entitles the Member or his

Authorized Representative to appeal the decision, utilizing LIBERTY’s

Appeals Procedures.

The External Review provision in this EOC only applies if the Adverse

Benefit Determination was made based on the Plan’s determination

that the denied service or supply was not necessary or that the

denied service or supply was determined to be experimental or

investigational.

NV_Patriot_01/10 - 27 -

An Adverse Benefit Determination is final if the Member has

exhausted all complaint and Appeal Procedures set forth herein for

the review of such Adverse Benefit Determination.

"Aesthetic Dentistry" means any dental procedure performed for

cosmetic purposes and where there is not restorative value.

“Authorized Representative” means a person designated by the

Member to act on his behalf in pursuing a Claim for Benefits, to file an

appeal of an Adverse Benefit Determination, or in obtaining an

External Review of a final Adverse Benefit Determination.

“Benefit Schedule” means the brief summary of benefits, limitations

and Copayments given to the Subscriber by LIBERTY. It is

Attachment A to this EOC.

“Calendar Year” means January 1 through December 31 of the

same year.

“Claim for Benefits” means a request for a Plan benefit or benefits

made by a Member in accordance with the Plan’s Appeals

Procedures, including any Pre-Service Claims (requests for Prior

Authorization) and Post-Service Claims (requests for benefit

payment).

“Contract Year” means the twelve (12) months beginning with and

following the Effective Date of the Group Enrollment Agreement

(GEA).

“Copayment” means the amount the Member pays directly to a Plan

Provider when a Covered Service is received.

“Covered Services” means the dental services, supplies and

accommodations for which the plan pays benefits under this Plan.

“Dental Director" means a Nevada licensed dentist who is

contracted with or employed by LIBERTY to provide professional

advice concerning dental care to Members under the applicable EOC.

"Dentist" means an individual who is licensed as a Doctor of Dental

Surgery (D.D.S.) or a Doctor of Dental Medicine (D.M.D.) in

accordance with applicable state laws and regulations and who is

practicing within the scope of such license.

NV_Patriot_01/10 - 28 -

“Dependent” means an Eligible Family Member or Qualified

Domestic Partner of the Subscriber's family who:

 meets the eligibility requirements of the Plan as set forth

in Section 1 of this EOC;

 is enrolled under this Plan; and

 for whom premiums have been received and accepted by

LIBERTY.

"Domestic Partner" means a person of at least 18 years of age has

registered for a domestic partnership with Subscriber under the laws

of the State of Nevada with the Nevada Secretary of State.

“Effective Date” means the initial date on which Members are

covered for services under the LIBERTY Plan provided any

applicable premiums have been received and accepted by LIBERTY.

"Elective Dentistry" means any dental procedure that is

unnecessary to the dental health of the patient as determined by

LIBERTY's Dental Director.

“Eligible Employee” means a natural person that:

A. Is a bona fide employee of the Group; and

B. Meets the criteria in Section 1.1

“Eligible Family Member” means a member of a Subscriber’s family

that is or becomes eligible to enroll for coverage under this Plan.

“Emergency Services” means Covered Services provided after the

sudden onset of a dental condition with symptoms severe enough to

cause a prudent person to believe that lack of immediate medical

attention could result in serious:

 jeopardy to his health;

 jeopardy to the health of an unborn child;

 impairment of a bodily function; or

 dysfunction of any bodily organ or part.

“Enrollment Date” means the first day of coverage under this Plan

or, if there is a Waiting Period, the first day of the Waiting Period.

“ERISA” means Employee Retirement Income Security Act of 1974,

as amended, including regulations implementing the Act.

NV_Patriot_01/10 - 29 -

“Evidence of Coverage” or “EOC” means this document, including

any attachments or endorsements, the Member identification card,

health statements and all applications received by LIBERTY.

“Group” means an employer or legal entity that has completed a

Group Application and signed a Group Enrollment Agreement with

LIBERTY for LIBERTY to provide Covered Services.

“Group Enrollment Agreement” or “GEA” means the agreement

signed by LIBERTY and Group that states the conditions for

coverage, eligibility and enrollment requirements and premiums.

“Initial Enrollment Period” means the period of time during which

an eligible person may enroll under this Plan, as shown in the GEA

signed by the Group.

“Dentally Necessary” or "Necessary" means a service or supply

needed to improve a specific condition or to preserve the Member’s

dental health and which, as determined by LIBERTY is:

 consistent with the diagnosis and treatment of the

Member

 the most appropriate level of service which can be safely

provided to the Member; and

 not solely for the convenience of the Member or the

Provider(s).

In determining whether a service or supply is Necessary,

LIBERTY may give consideration to any or all of the following:

 the likelihood of a certain service or supply producing a

significant positive outcome;

 reports in peer-review literature;

 evidence based reports and guidelines published by

nationally recognized professional organizations that

include supporting scientific data;

 professional standards of safety and effectiveness that

are generally recognized in the United States for

diagnosis, care or treatment;

 the opinions of independent expert Dentists in the health

specialty involved when such opinions are based on

broad professional consensus; or

 other relevant information obtained by LIBERTY.

NV_Patriot_01/10 - 30 -

Services will not automatically be considered Dentally

Necessary simply because they were prescribed by a

Dentist.

“Member” means a person who meets the eligibility requirements of

Section 1, who has enrolled under this Plan and for whom premiums

have been received by LIBERTY.

“Non-Plan Provider” or "Out-of-network Provider" means a

Provider who does not have an independent contractor agreement

with LIBERTY.

“Open Enrollment Period” means an annual thirty-one (31) day

period of time during which Eligible Employees and their Eligible

Family Members may enroll under this Plan.

"Plan” means LIBERTY Dental Plan of Nevada, Inc.

“Plan Provider” means a Provider who has an independent

contractor agreement with LIBERTY to provide certain Covered

Services to Members. A Plan Provider’s agreement with LIBERTY

may terminate, and a Member will be required to select another Plan

Provider.

“Post-Service Claim” means any Claim for Benefits under a Group

Health Plan regarding payment of benefits that is not considered a

Pre-Service Claim.

“Prescription Drug” means a Federal Legend drug or medicine that

can only be obtained by a prescription order or that is restricted to

prescription dispensing by state law. It also includes insulin and

glucagon.

“Pre-Service Claim” means any Claim for Benefits under a Group

Health Plan with respect to which the terms of the Plan condition

receipt of the benefit, in whole or in part, on approval of the benefit in

advance of obtaining medical care.

“Prior Authorization” or “Prior Authorized” means a system that

requires a Provider to get approval from LIBERTY before providing

non-emergency health care services to a Member for those services

to be considered Covered Services. Prior authorization is not an

agreement to pay for a service.

"Qualified Domestic Partner" means a Domestic Partner that is in a

Qualified Domestic Partnership with Subscriber.

"Qualified Domestic Partnership" means a relationship between

Subscriber and a Domestic Partner in which:

NV_Patriot_01/10 - 31 -

 Both the Subscriber and the Domestic Partner are at

least 18 years of age;

 The Subscriber and the Domestic Partner have

chosen to share one another’s lives in an intimate

and committed relationship;

 Have entered into a domestic partnership out of their

own free will;

 Have filed the required affidavits for the formation of

a Domestic Partnership under the laws of the State of

Nevada with the Secretary of State for the State of

Nevada;

 The Subscriber and the Domestic Partner are jointly

responsible for the cost of food, shelter and other

basic living expenses of the other;

 The Subscriber and the Domestic Partner are

unmarried to each other or any other person;

 The Subscriber and the Domestic Partner are not in

any other domestic partnership;

 The Subscriber and the Domestic Partner are not

related by blood to a degree that would prohibit a

spousal relationship;

 The Subscriber and the Domestic Partner are both

legally competent to consent to contract; and

 The Subscriber and the Domestic Partner have

shared the same regular and permanent actual

residence for a period of at least 12 months and

intend to do so indefinitely.

“Referral” means a recommendation for a Member to receive a

service or care from another Provider or facility.

“Retrospective” or “Retrospectively” means a review of an event

after it has taken place.

NV_Patriot_01/10 - 32 -

“Rider” means a provision added to the agreement or the EOC to

expand benefits or coverage.

“Service Area” means the geographical area where LIBERTY is

licensed to operate. Subscribers must live or work in the Service

Area to be covered under this Plan. Dependent children that are

covered under this Plan, due to a court order, do not have to reside

within the Service Area.

“Specialist” means a Plan Provider who has an independent

contractor agreement with LIBERTY to assume responsibility for the

delivery of specialty dental services to Members. These specialty

dental services include any services not related to the ongoing

primary or regular dental care of a patient. Specialty dental services

include specific fields of dentistry such as endodontics, periodontics,

oral surgery, or orthodontics.

“Subscriber” means an employee of the Group who meets the

eligibility requirements, who has enrolled under the Plan, and for

whom premiums have been received.

"Waiting Period" means the period of time as established by the

Group that must pass before coverage for an Eligible Employee or

Dependent can become effective.