- 1 -
LIBERTY Dental Plan of Nevada, Inc.
Evidence of Coverage
POS Plans
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.
- 2 -
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
- 3 -
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. meet 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.
A child by birth. Adopted child. Stepchild. 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 of a Subscriber
meeting one of these conditions is eligible for coverage under this Plan up to the child’s
twenty-sixth (26
th
) birthday unless such child is eligible for employer-sponsored coverage
(other than coverage through the Subscriber). The children and spouse of a dependent child
are excluded from coverage.
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.
- 4 -
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:
A foster child.
A child placed in the Subscriber's home other than for the purpose of adoption.
A grandchild other than:
1. A grandchild that has been adopted by the grandparents and/or has been placed
in the home of the grandparents for the purposes of adoption; or
2. For the first thirty-one (31) days after birth only, a grandchild that is also the child
of a Dependant as that term is defined in Section 1.1 of this EOC.
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.
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 -
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.
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.
- 6 -
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.
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.
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 by offering three tiers of
coverage EPO, PPO, and Out-of-Network. You will find the most affordable care is available
through Tier I EPO Plan Providers. When you choose to receive your care from any dentist that
is an EPO Plan Provider, your costs will be limited by the costs identified in the Schedule of
Benefits. You will also not need to submit any claim forms when you receive your care from an
EPO Plan Provider. To receive in-network benefits for care provided by a Specialist your EPO
Plan Provider must initiate the referral process with LIBERTY. LIBERTY will then refer you to a
Specialist who is an EPO Plan Specialty Provider for approved Specialty services.
If you choose to receive care from a dentist that is not a Tier I EPO Plan Provider your benefit will
be more limited and you will have an annual deductible and an annual maximum.
- 7 -
When you choose to receive your care from any dentist that is a Tier II PPO Plan Provider, your
costs will be limited by the PPO Plan Provider’s contracted fees. You will only be responsible for
your deductible, your co-insurance percentage (based on your Plan coverage) of the PPO Plan
Provider’s contracted rate, non-covered services, and amounts over your annual maximum
payable by the Plan. You will also not need to submit any claim forms when you receive your care
from a Plan Provider.
If you receive care from a Tier III Out-of-Network Provider, the Plan will pay the applicable
percentage (based on your Plan coverage) of the regional usual and customary fees and you will
be responsible for any amount charged by the Out-of-Network Provider over and above that
payable by the Plan. Out-of-Network Providers may ask you to pay the full amount of the
charges and have you submit the claim to LIBERTY for reimbursement. You will be
responsible for the difference in what the Out-of-Network Provider charges and the total
amount that LIBERTY pays.
In addition, care by a Specialist that was not approved by LIBERTY following the Specialty
Referral process noted above will be paid under Tier II if the specialist is in the PPO Plan network
or Tier III if the specialist is not in the PPO Plan network.
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.
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.
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 I In-network benefits must be obtained from EPO Plan Providers. The Benefit Schedule
identifies the member copayments that are to be paid to Tier I EPO Plan Providers at the time of
service.
Tier II In-network benefits must be obtained from PPO Plan Providers. Plan payment is based on
the applicable percentages of the PPO Plan Providers contracted fees. Deductibles and
maximums apply for care received from PPO Plan Providers.
Tier III Out-of-network benefits can be obtained from any dentist licensed in the United States.
Plan payment is based on the applicable percentages of the regional usual and customary fees
Deductibles and maximums apply for care received from dentists and Specialists that are not
Plan Providers. You will be responsible for any charges over the Plan Pays amount.
4.2 CLAIM PAYMENTS
Tier I EPO Plan Providers are paid an amount agreed upon between the Plan and the EPO Plan
Provider plus any copayment from the Member required by the Benefit Schedule.
Tier II PPO Plan Providers are paid based on the applicable percentages of the PPO Plan
Providers contracted fees.
- 8 -
Tier III out-of-network providers are paid an amount based on the applicable percentages of the
regional usual and customary fees. The Plan's payment to an out-of-network provider may not
fully compensate the provider for the services provided to the Member. The Member is
responsible for the difference between the amount paid by the Plan to an out-of-network provider
and the out-of-network provider's charge.
When you receive services from an Out-of-Network provider, you may be asked to pay 100% of
the charges at the time of service. You must submit a claim form with the supporting
documentation to LIBERTY when requesting reimbursement. When obtaining care from a Tier I
EPO Plan Provider or a Tier II PPO Provider, the Plan Provider will submit the claim form on your
behalf. LIBERTY accepts standard American Dental Association claim forms which most
providers have in their office. Claims forms are also available from LIBERTY.
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. If Member
authorizes payment directly to the Provider, a check will be mailed to that Provider. A check will
be mailed to the Member directly if payment directly to the Provider is not authorized. Member
will receive an explanation of how the payment was determined.
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 Tier I EPO Plan Provider if
possible. Should no Tier I EPO Plan Provider be available in a fifty (50) mile radius you can seek
treatment from any licensed dentist. In such an event, the Plan will reimburse you for the cost of
qualified emergency services received from a non-EPO Plan Provider up to a maximum of
seventy-five dollars ($75), less any applicable member co-payments based on the Tier I EPO In-
Network Benefits. Any non-qualified emergency services will be considered under either the Tier
II PPO Benefits if a PPO Plan Provider is used or the Tier III Out-of-Network Benefits if the
Provider is not a PPO Plan Provider.
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.
- 9 -
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.