Member Handbook. Access Dental Plan Los Angeles County. Combined Evidence of Coverage and Disclosure Form

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1 Member Handbook What you need to know about your benefits Access Dental Plan Combined Evidence of Coverage and Disclosure Form 2018 Los Angeles County

2 Page 2 of Other languages and formats Other languages You can get this Member Handbook and other plan materials for free in other languages. Call (TTY ). The call is free. Other formats You can get this information for free in other formats, such as Braille, large print and audio. Call (TTY ). The call is free. Interpreter services For free interpreter, linguistic and cultural services and help available 24 hours a day, 7 days a week, or to get this handbook in a different language, call (TTY ). The call is free.

3 Page 3 of 48 Laotian ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: ). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Farsi توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد. با ( (TTY: تماس بگیرید. Eastern Punjabi ਧ ਆਨ ਧ ਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲ ਹ, ਤ ਭ ਸ਼ ਧ ਚ ਸਹ ਇਤ ਸ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬ ਹ (TTY: ) 'ਤ ਕ ਲ ਕਰ Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 1-xxx-xxx-xxxx). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Mon-Khmer, Cambodian ប រយ ត ន បរ ស នជ អ នកន យ យ ភ ស ខ ម រ, បសវ ជ ន យខ នកភ ស ប យម នគ ត ឈ ន ល គ អ ចម នស រ រ រ បរ អ នក ច រ ទ រស ព ទ (TTY: ) Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: (. Hindi ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: ) पर क ल कर Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Armenian ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) ): Thai เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: (. through Friday, from 8:00 AM to 6:00 PM. The call is free. Or call the California Relay

4 Page 4 of Notice of non-discrimination Discrimination is against the law. Access Dental Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Access Dental Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, sex or gender identity. Access Dental Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (braille, large print, audio, accessible electronic formats, and other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Jennifer Felice. If you believe that Access Dental Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Jennifer Felice, Grievance and Appeals Department P.O. Box , Sacramento, CA (TTY ) grievancedept@premierlife.com You can file a grievance in person or by mail, fax or . If you need help filing a grievance, Jennifer Felice is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington, D.C , (TDD) Complaint forms are available at

5 Page 5 of Welcome to Access Dental Plan! Thank you for joining Access Dental Plan (ADP). ADP is a dental plan for people who have Medi-Cal. We work with the State of California to help you get the dental care you need. Member Handbook This Member Handbook tells you about your coverage under ADP. Please read it carefully. It will help you understand and use your benefits and services. It also explains your rights and responsibilities as a member of ADP. This Member Handbook is also called the Evidence of Coverage (EOC). It is only a summary of ADP rules and policies. If you would like to learn the exact terms and conditions of coverage, you may request a copy of the contract from Member Services. Call (TTY ) to ask for a copy of the contract. You may also ask for another copy of the Member Handbook at no cost to you or visit our website at to view the Member Handbook. Contact us We are here to help. If you have questions, call (TTY ). We are here 8:00am to 6:00pm. The call is free. You can also visit us online at any time at Thank you, Access Dental Plan 8890 Cal Center Dr. Sacramento, CA

6 Page 6 of Table of contents 1.Other languages and formats Notice of non-discrimination Welcome to Access Dental Plan!... 5 Member Handbook... 5 Contact us Table of contents Getting started as a member... 9 How to get help... 9 Member Services... 9 Who can become a member... 9 Identification (ID) cards... 9 Ways to get involved as a member Public Policy Committee About your dental plan Dental plan overview When your coverage starts and ends How your dental plan works Changing dental plans Continuity of care Costs Member costs How a dentist gets paid Asking us to pay a bill How to get dental care Getting dental services... 15

7 Page 7 of 48 Routine care Emergency/Urgent dental care Where to get dental care Dental Provider Directory Dental provider network In network Out of network Dentists Primary care dentist (PCD) Choice of Dentists Appointments and visits Payment Referrals Pre-approval Second opinions Timely Access to Care Benefits and services What your dental plan covers Summary of benefits Pediatric services for dental care Non-Emergency Medical Transportation Non-Medical Transportation What your dental plan does not cover Services you cannot get through ADP or Medi-Cal Coordination of benefits Rights and responsibilities Your rights Your responsibilities Notice of Privacy Practices Notice about laws Notice about Medi-Cal as a payer of last resort... 37

8 Page 8 of 48 Notice of Adverse Benefit Determination Reporting and solving problems Complaints Appeals Binding Arbitration State Hearings Fraud, waste and abuse Important numbers and words to know Important phone numbers Words to know... 44

9 Page 9 of Getting started as a member How to get help We want you to be happy with your dental care. If you have any questions or concerns about your care, we want to hear from you! Member Services ADP Member Services is here to help you. We can: Answer questions about your dental plan and covered services Help you choose a primary care dentist (PCD) Tell you where to get the care you need Offer interpreter services if you do not speak English Offer information in other languages and formats If you need help, call (TTY ). We are here 8:00am to 6:00pm. The call is free. You can also visit us online at any time at Who can become a member You qualify for ADP because you qualify for Medi-Cal and live in Los Angeles County. For questions about enrollment, call Health Care Options at (TTY ). Or visit You can ask questions about qualifying for Medi-Cal at your local county human services office. Find your local office at or call (TTY) to reach Covered California. Identification (ID) cards As a member of ADP, you will get a dental plan ID card. You must show your dental plan ID card and your Medi-Cal Benefits Identification Card (BIC) when you get any dental services. You should carry both cards with you at all times. Here is a sample dental plan ID card to show you what yours will look like:

10 Page 10 of 48 Do not let anyone else use your ID card. If someone else uses your ID card you will be charged for the services. If you do not get your dental plan ID card within a few weeks of enrolling, or if your card is damaged, lost or stolen, call Member Services right away. We will send you a new card. Call (TTY ). Ways to get involved as a member ADP wants to hear from you. Each year, we have meetings to talk about what is working well and how we can improve. Members are invited to attend. Join us and tell us what you think! Public Policy Committee We have a group called the Public Policy Committee. This group is made up of members, Plan dental providers and a member of the Board of Directors. The group talks about how to improve ADP policies and is responsible for: Advise the Board of Directors about how to assure member satisfaction. Reviewing complaints and grievances we received. Providing input in our member surveys and oral health programs. Membership is voluntary. Members will be paid $ per meeting for participating. If you would like to be a part of this group, call (TTY ). Or fill out the Public Policy Committee form.

11 Page 11 of About your dental plan Dental plan overview ADP is a dental plan for people who have Medi-Cal in Los Angeles County. We work with the State of California to help you get the dental care you need. You may talk with one of our Member Services Representatives to learn more about the dental plan and how to make it work for you. Call (TTY ). When your coverage starts and ends When you enroll in ADP, you will receive an ADP Member ID card within seven (7) calendar days of enrollment. Please show this card every time you go for any service under the ADP. Coverage begins at 12:01 AM on the first day of the month. Each month the Department of Health Care Services (DHCS) sends a list of approved members to ADP. That list controls coverage. You may ask to end your ADP coverage and choose another dental plan at any time. You can also ask to end your Medi-Cal. You must follow DHCS procedures if you ask to end your coverage. Sometimes ADP can no longer serve you. ADP must end your coverage if: You move out of the county or are in prison You no longer have Medi-Cal You terminate your plan coverage Your plan terminates you for violent behavior or fraud The Plan has the right to request to have you disenrolled. Reasons for disenrollment shall include verbal or physical abuse, disruptive behavior, and not following plan policies with out-of-network providers. If you are a Native American, you do not have to enroll in a Medi-Cal managed care dental plan. If you have been enrolled in ADP, you can ask to leave at any time. You can also get dental care at an Indian Health Service (IHS) Division of Oral Health (DOH) site. How your dental plan works ADP is a dental plan contracted with DHCS. ADP is a dental managed care plan. Managed care plans are a cost-effective use of dental care resources that improve

12 Page 12 of 48 dental care access and assure quality of care. ADP works with dentists and other providers in our service area to provide dental care to you, our member. Member Services will tell you how ADP works and how to get the dental care you need. Member Services can help you: Find a primary care dentist (PCD) Schedule an appointment with your PCD Get a new ADP ID card Get information about covered and non-covered services Get transportation services Understand how to report and solve grievances and appeals Get a list of dentists Request member materials Answer other questions you may have To learn more, call (TTY ). Or find member service information online at Changing dental plans You may leave ADP and join another dental plan at any time. Call Health Care Options at (TTY ) to choose a new plan. You can call between 8:00 a.m. and 5:00 p.m. Monday through Friday, or visit It takes about 45 calendar days to process your request to leave ADP. To find out when Health Care Options has approved your request, call (TTY ). If you want to leave ADP sooner, you may ask Health Care Options for an expedited (fast) disenrollment. If the reason for your request meets the rules for expedited disenrollment, you will get a letter to tell you that you are disenrolled. You may ask to leave ADP in person at your local county human services office. Find your local office at or call to reach Covered California. Continuity of care If you now see dentists who are not in the ADP network, you may be able to keep seeing them for up to 12 months. If your dentists do not join our network by the end of 12 months, you will need to switch to dentists in the ADP network. A member can continue services from a dentist not in the ADP network in specific cases. Members should request services by calling ADP will provide the member a decision in writing within 5 business days of the receipt of the request.

13 Page 13 of 48 ADP requires the dentist to agree in writing to be subjected to the same contractual terms and conditions that are imposed upon current contracting providers. The dentist must agree to comply with ADP terms and conditions. The dentist must accept the payment rates provided by ADP. College students who move to a new county If you move to a new county to attend college, you may still be able to get ADP services, even if ADP does not serve your new county. Or you may be able to get services through regular Medi-Cal, also known as Fee-for-Service (FFS) Medi-Cal. This is called continuity of care. ADP provides continuity of care services for college students if it is an emergency. To learn more about continuity of care services, call (TTY ). Dentists who leave ADP If your dentist stops working with ADP, you may be able to keep getting services from that dentist. This is another form of continuity of care. ADP provides continuity of care services for: Acute Conditions Newborn Children between Birth and Age 36 Months Surgery or Other Procedure Members may request continuation of care by calling Member Services at during normal business hours. ADP will review the request and give you an answer in writing within 5 business days. ADP provides continuity of care services if: The treating dentist is terminated while in the middle of treatment. You are a new member who is in the middle of treatment with a dentist who is not contracted with ADP. ADP does not provide continuity of care services if: The dentist does not want to agree to ADP terms. The dentist does not accept the payment rates by ADP. Unless Plan and Provider agree otherwise: The dentist shall be paid in a way similar to those who are contracted. Payment could be capitation or fee-for-service. To learn more about continuity of care services, call (TTY ).

14 Page 14 of 48 Costs Member costs ADP serves people who qualify for Medi-Cal. ADP members do not have to pay for covered services. You will not have premiums, co-pays or deductibles. You will have to pay for services that are not covered benefits under the Medi-Cal program, unless the dentist gets pre-approval (prior authorization). You may have to pay a portion of your dental care costs each month before benefits become effective. This is called your share of cost. The amount of your share of cost depends on your income and resources. For questions about share of cost, contact your local county human services office. Find your local office at How a dentist gets paid ADP pays dentists in these ways: Capitation payments o ADP pays some dentists a set amount of money every month for each ADP member. This is called a capitation payment. ADP and dentists work together to decide on the payment amount. Fee-for-service payments o Some dentists give dental care to ADP members and then send ADP a bill for the services they provided. This is called a fee-for-service payment. ADP and dentists work together to decide how much each service costs. Bonus or incentive payments o ADP pays some dentists more for seeing members every year. ADP also pays some dentists more for doing preventive work like a cleaning. To learn more about how ADP pays dentists, call (TTY ). Asking us to pay a bill If you get a bill for a covered service, call Member Services right away at (TTY ). If you pay for a service that you think ADP should cover, file a claim with us. Call (TTY ) to ask for a claim form, or for help to file a claim. Use a claim form and tell us in writing why you had to pay. We will review your claim to see if you can get money back.

15 Page 15 of How to get dental care Getting dental services PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED. You can begin to get dental care services on your effective date of coverage. Keep your dental plan ID card and Medi-Cal BIC card with you. Never let anyone else use your ID card or BIC card. Dentists are also called dental providers. New members must choose a primary care dentist (PCD) in our network. The ADP network is a group of dentists who work with us. You must choose a PCD within 30 days from the time you become a member in ADP. If you do not choose a PCD, we will choose one for you. You may choose the same PCD or different PCDs for all family members in ADP. If you have a dentist you want to keep, or you want to find a new PCD, you can look in the dental Provider Directory. It has a list of all PCDs in our plan network. The dental Provider Directory has other information to help you choose. If you need a dental Provider Directory, call (TTY ). You can also find the dental Provider Directory on our website at If you cannot get the care you need from a participating dental provider in our network, your PCD must ask ADP for approval to send you to an out-of-network provider. Read the rest of this chapter to learn more about PCDs, our dental Provider Directory and our dental provider network. When you call for an appointment with your PCD, tell the person who answers the phone that you are a member of ADP. Give your dental plan ID number. To get the most out of your dental visit: Bring your Medi-Cal identification card (BIC) Bring your dental plan ID card Bring your valid California ID card or driver's license Know your Social Security Number Bring your list of medications Be ready to talk with your PCD about any dental problems you've noticed for yourself or your children. Be sure to call your PCD s office if you are going to be late or cannot go to your appointment.

16 Page 16 of 48 Routine care Oral health is an important part of overall health and well-being. The Medi- Cal Dental program recommends that children begin seeing a dentist by their first tooth first birthday. Routine care is regular dental care. ADP covers routine care from your PCD. Some services may be referred to dentists that are specialists, and some services may require pre-approval (prior authorization). All dental services must meet Medi-Cal Dental program requirements to be covered. Dental services that may be covered for children are: Exams and x-rays Cleanings Fluoride treatments Sealants Fillings Crowns Tooth extractions Root canals Braces Appliances to replace missing teeth Dental services that may be covered for adults are: Exams and x-rays Cleanings and deep cleanings (scaling and root planing) Fluoride treatments Fillings Anterior and posterior root canals (front and back teeth) Tooth extractions Prefabricated and laboratory crowns Full and partial dentures Other medically necessary dental services For a full list of child and adult dental services, read Benefits and services starting on page 23 in this handbook. Emergency/Urgent dental care ADP covers emergency/urgent dental care. Emergency/urgent dental care does not need a referral. If you have an emergency/urgent please contact your dentists office. If it is after hours your dentist will have emergency/urgent processes on their voic . If they do not answer please call ADP. We have an on-call dentist who will assist you. You may also call 911 or go to the nearest hospital. Emergency/urgent services may be done by any dentist. Dentists who are not contracted with ADP may charge you up

17 Page 17 of 48 front. If you pay for covered emergency services ADP will pay you back. Emergency/urgent services that do not meet the definition will not be covered. If you need help, call (TTY ). We are here Monday through Friday, from 8:00 AM to 6:00 PM. The call is free. Where to get dental care You will get most of your care from your PCD. Your PCD will give you most of your routine dental care. Your PCD will refer (send) you to specialists if you need them. If you need help to schedule an appointment, call (TTY ). We are here Monday through Friday, from 8:00 AM to 6:00 PM. The call is free. If you need emergency/urgent dental care, call your PCD. If you would like assistance to schedule an appointment, or are not in your home area, call (TTY ). For medical emergencies, call 911 or go to the nearest emergency room. Dental Provider Directory The ADP dental Provider Directory lists providers that participate in the ADP network. The network is the group of providers that work with ADP. The ADP dental Provider Directory lists dentists including Federally Qualified Health Centers (FQHCs) and dental specialists. The dental Provider Directory has names, provider addresses, phone numbers, business hours and languages spoken. It tells if the provider is taking new patients. It gives the level of physical accessibility for the building. You can find the online dental Provider Directory at If you need a printed Provider Directory, call (TTY ). Dental provider network The dental provider network is the group of dentists and specialty dentists that work with ADP. You will get your covered services through our network. In network You will use dentists in the ADP network for your dental care needs. You will get preventive and routine care from your PCD. You will also use specialists and other providers in our network.

18 Page 18 of 48 To get a dental Provider Directory of network providers, call (TTY ). Or you can find our dental Provider Directory online at For urgent or emergency dental care, call your PCD. If you would like assistance to schedule an appointment, or are not in your home area, call (TTY ). For medical emergency care, call 911 or go to the nearest emergency room. Out of network Out-of-network providers are those that do not have an agreement to work with ADP. Except for urgent or emergency care, you may have to pay for care from providers who are out of network. If you need covered dental care services, you may be able to get them out of network at no cost to you as long as they are medically necessary and not available in the network. If you need help with out-of-network services, call (TTY ). If you are outside of our service area and need care that is not an emergency, call your PCD right away. Or call (TTY ). If you have questions about out-of-network or out-of-area care, call (TTY ). Dentists You will choose a primary care dentist (PCD) from the ADP dental Provider Directory. Your PCD must be a participating dentist. This means the dentist is in our network. To get a copy of our dental Provider Directory, call (TTY ). You should also call if you want to check to be sure the PCD you want is taking new patients. If you were seeing a dentist for certain conditions before you were a member of ADP, you may be able to keep seeing that dentist. This is called continuity of care. You can read more about continuity of care on page 12 of this handbook. To learn more, call (TTY ). If you need a dental specialist, your PCD will give you a referral to a specialist in our network. Remember, if you do not choose a PCD, we will choose one for you. You know your dental care needs best, so it is best if you choose.

19 Page 19 of 48 If you want to change your PCD, you must choose a PCD from our dental Provider Directory. Be sure the PCD is taking new patients. To make changes, please call Member Services at (TTY ), or visit Primary care dentist (PCD) New members must choose a PCD within 30 days of enrolling in ADP. You may choose a general dentist as your PCD. You can also choose a Federally Qualified Health Center (FQHC), community clinic, Native American Health Clinic or other primary care facility that has dental services as your PCD if they are in the ADP network and if you qualify for their services. These are centers that are located in areas that do not have many dental care services. You can choose the same or different PCDs for everyone in your family who is a member of ADP. If you do not choose a PCD within 30 days, a dentist who works with member care in ADP will choose a PCD for you. Your PCD will: Get to know your dental needs Keep your dental records Give you the preventive and routine dental care you need Refer (send) you to a specialist if you need one You can look in the dental Provider Directory to find a PCD in the ADP network. The dental Provider Directory has a list of FQHCs that work with ADP. You can find our dental Provider Directory online at Or call (TTY ). You can also call to find out if the PCD you want is taking new patients. Choice of Dentists You know your dental care needs best, so it is best if you choose your PCD. It is best to stay with one PCD so he or she can get to know your dental care needs. However, if you want to change to a new PCD, you can change one time each month. You must choose a PCD who is in the ADP dental provider network and is taking new patients. Your new choice will become your PCD on the first day of the next month after you make the change. To change your PCD, call (TTY ).

20 Page 20 of 48 We may ask you to change your PCD if the PCD is not taking new patients, has left our network, or does not give care to patients your age. ADP or your PCD may also ask you to change to a new PCD if you cannot get along with or agree with your PCD, or if you miss or are late to appointments. If we need to change your PCD, we will tell you in writing. If you change PCDs, you will get a new dental plan member ID card in the mail. It will have the name of your new PCD. Call Member Services if you have questions about getting a new ID card. Appointments and visits When you need dental care: Call your PCD Have your ADP ID number ready on the call Leave a message with your name and phone number if the office is closed Take your BIC and dental plan ID card to your appointment Bring an identification card or driver license Be on time for your appointment Call right away if you cannot keep your appointment or will be late Have your questions ready in case you need them Payment You do not have to pay any deductibles or co-pays for covered services. In most cases, you will not get a bill from a dentist. You may get an Explanation of Benefits (EOB) or a statement from a dentist or ADP. EOBs and statements are not bills. If you do get a bill, call (TTY ). Tell us the amount charged, the date of service and reason for the bill. If you get a bill or are asked to pay a co-pay, you can also file a claim form. You will need to tell us in writing why you had to pay for the item or service. We will read your claim and decide if you can get money back. For questions or to ask for a claim form, call (TTY ). Referrals Your PCD will give you a referral to send you to a specialist if you need one. A specialist is a dentist who has extra education in one area of dentistry. All referrals will be sent to ADP for approval. ADP will send you the response in the mail. If approved, ADP will choose the best specialist for you. You will need to schedule an appointment with the approved specialist. ADP can help you set up a time to see the specialist. Your PCD may give you a form to take to the specialist dentist. The specialist dentist will fill out the form and send it back to your PCD.

21 Page 21 of 48 If you want a copy of our referral policy, call (TTY ). You do not need a referral for: PCD visits Urgent or emergency care Pre-approval For some types of care, your PCD or specialist dentist will need to ask us before you get the care. This is called prior authorization or pre-approval. It means that ADP agrees that the care is medically necessary. Care is medically necessary if it is to prevent and eliminate orofacial disease, infection, and pain, to restore the form and function of the dentition, or to correct facial disfiguration or dysfunction. Dental services must meet Medi-Cal program rules for medical necessity. These dental services need pre-approval, even if you receive them from a provider in the ADP network: Root canals Crowns Full dentures Denture relines Deep cleanings (scaling and root planing) General anesthesia and IV sedation Other dental services your dentist recommends may also require pre-approval. Services out of the ADP service area require pre-approval. For urgent or emergency care when you are outside your service area, call ADP at (TTY ) for assistance. For some services, such as care from a specialist dentist, you need pre-approval if you get the care out of network. We will decide within 5 business days, for routine service, or 72 hours for urgent care. There is a shorter timeframe when medically necessary under the Health and Safety Code Section (h)(2). If you ask us to approve certain types of dental services, we review the request to decide if the care is medically necessary and covered. We do not pay our reviewers to deny coverage or dental services. If we do not approve the care, we will tell you why. ADP will contact you if we need more information or more time to review your request.

22 Page 22 of 48 Second opinions You might want a second opinion about care your PCD says you need, or about your diagnosis or treatment plan. For example, you may want a second opinion if you are not sure you need a prescribed treatment or surgery. To get a second opinion, call your PCD. Your PCD can refer you to a network provider for a second opinion. Or call (TTY ). We will pay for a second opinion if you or your PCD asks for it. You will be sent to a network dentist if you need a second opinion. If you have a diagnosis that may threaten loss of life, substantial impairment, including a serious chronic medical condition we will decide within 72 hours. Members interested in obtaining the timeline for authorizing second dental opinions can contact the Plan at: Access Dental Plan Referrals Department P.O. Box: Sacramento, CA ext The cost of obtaining the second opinion will be paid for by ADP. Call Member Services at (TTY ). If we deny your request for a second opinion, you may appeal. To learn more about appeals, go to page 40 in this handbook. Timely Access to Care One of your rights is to timely dental care. This means that you have the right to certain appointment wait times. An appointment wait time is the time from the initial request to the earliest date offered. Initial Appointment within 4 weeks Routine Appointment (non-emergency) within 4 weeks Preventive Dental Care Appointment within 4 weeks Specialist Appointment within 30 business days from approved request for adults Specialist Appointment within 30 calendar days from approved request for children Emergency/Urgent Appointment within 24 hours from the request for appointment If you are asking for a specific date and time these standards may not apply.

23 Page 23 of 48 If your dentist office offers a later appointment call us immediately. We will help you set your appointment or file a complaint against your provider. Language and interpreter services are available for you. You can ask us to send an interpreter to your appointment. You must ask at least 2 weeks prior to your appointment. 8. Benefits and services What your dental plan covers In this section, we explain all of your covered services as a member of ADP. Your covered services are free as long as they are medically necessary. Care is medically necessary if it is to prevent and eliminate orofacial disease, infection, and pain, to restore the form and function of the dentition, and to correct facial disfiguration or dysfunction. We offer these types of dental services: Type of service Diagnostic Preventive Restorative Endodontic Periodontal Prosthodontics, Removable Oral and Maxillofacial surgery Orthodontics Adjunctives Examples Exams and x-rays Cleanings, fluoride treatments, sealants Fillings, crowns Pulpotomies, root canals Deep cleaning, gum surgery Immediate and complete dentures, relines Extractions Braces Sedation, general anesthesia Read the summary of benefits and each of the sections below to learn more about the exact services you can get.

24 Page 24 of 48 Summary of benefits Benefit Not a benefit Procedure Oral Evaluation (Under age 3)* Initial Exam (Age 3 and above) Periodic Exam (Age 3 and above) Prophylaxis Fluoride Restorative Services - Amalgams/Composites/Prefabricated Crowns Laboratory Processed Crowns ** Scaling and Root Planing * ** Full Mouth Debridement Periodontal Maintenance Anterior Root Canals Posterior Root Canals Partial Dentures Full Dentures Extractions Emergency Services Exceptions: Full Scope Pregnant and 60 days postpartum Limited Scope Regional Center Consumers Residing in a Facility (SNF/ICF) * Only a benefit under age 3 ** 1. Not a benefit under age Over age 21, allowable under special circumstances for posterior teeth. A benefit only for the treatment of posterior teeth acting as an abutment for an existing removeable partial denture with cast clasps and rest. OR When a treatment plan includes an abutment crown and removeable partial denture (D5213 or D5214). Both shall be submitted on the same preapproval. *** Not a benefit under age 13. Allowable under special circumstances.

25 Page 25 of 48 Pediatric services for dental care Dental care We cover dental services for children through the month of their 21st birthday. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services We cover EPSDT services. EPSDT services include all services covered by Denti-Cal. If you are under 21 you may receive additional medically necessary services. These services are in addition to the regular Denti-Cal benefits. If you need one of these additional services your dentist will ask us. All requests are sent to DHCS for approval. If you want more information on EPSDT benefits, call (TTY ). Non-Emergency Medical Transportation You are entitled to use Non-Emergency Medical Transportation (NEMT) when you physically or medically are not able to get to your medical appointment by car, bus, train, or taxi, and the plan pays for your dental condition. NEMT is an ambulance, litter van, wheelchair van or air transport. NEMT is not a car, bus or taxi. ADP allows the lowest cost NEMT for your medical needs when you need a ride to your appointment. That means, for example, if you are physically or medically able to be transported by a wheelchair van, ADP will not pay for an ambulance. You are only entitled to air transport if your medical condition makes any form of ground transportation not possible. NEMT must be used when it is: Physically or medically needed as determined with a written prescription by a physician; or You are not able to physically or medically use a bus, taxi, car or van to get to your appointment; Approved in advance by ADP with a written prescription by a physician. To ask for NEMT, please call ADP at at least 10 business days (Monday- Friday) before your appointment. For urgent appointments, please call as soon as possible. Please have your member ID card ready when you call. Limits of NEMT There are no limits for receiving NEMT to or from dental appointments covered under ADP when a provider has prescribed it for you. NEMT is not covered if you choose a PCD that is out of the area. ADP will work to find a PCD who is closer to you.

26 Page 26 of 48 What Does Not Apply? If your physical and medical condition allows you to get to your medical appointment by car, bus, taxi, or other easily accessible method of transportation. Transportation will not be provided if the service is not covered by ADP. A list of covered services is in this member handbook. Cost to Member There is no cost when transportation is authorized by ADP. Non-Medical Transportation You can use Non-Medical Transportation (NMT) when you are: Traveling to and from an appointment for an ADP covered service prescribed by your provider. ADP allows you to use a car, taxi, bus, or other public/private way of getting to your medical appointment for plan-covered medical services including mileage reimbursement when transportation is in a private vehicle arranged by the beneficiary and not through a transportation broker, bus passes, taxi vouchers or train tickets. ADP allows the lowest cost NMT type for your medical needs that is available at the time of your appointment. To ask for NMT services, please call ADP at at least 10 business days (Monday-Friday) before your appointment or call as soon as you can when you have an urgent appointment. Please have your member ID card ready when you call. Limits of NMT There are no limits for receiving NMT to or from dental appointments covered under ADP when a provider has prescribed it for you. NEMT is not covered if you choose a PCD that is out of the area. ADP will work to find a PCD who is closer to you. What Does Not Apply? NMT does not apply if: An ambulance, litter van, wheelchair van, or other form of NEMT is medically needed to get to a covered service. The service is not covered by ADP. A list of covered services is in this member handbook. Cost to Member There is no cost when transportation is allowed by ADP. What your dental plan does not cover

27 Page 27 of 48 Services you cannot get through ADP or Medi-Cal There are some services that neither ADP nor Medi-Cal will cover, including: California Children s Services (CCS) Read each of the sections below to learn more. Or call (TTY ). California Children s Services (CCS) CCS is a state program that treats children under 21 years of age with certain health conditions, diseases or chronic health problems and who meet the CCS program rules. If ADP or your PCD believes your child has a CCS condition, he or she will be referred to the CCS program. CCS program staff will decide if your child qualifies for CCS services. If your child can get these types of care, CCS providers will treat him or her for the CCS condition. ADP will continue to cover types of service that do not have to do with the CCS condition. ADP does not cover care given by the CCS program. For CCS to cover these problems, CCS must approve the provider, services and equipment. CCS does not cover all problems. CCS covers most problems that physically disable or that need to be treated with medicines, surgery or rehabilitation (rehab). CCS covers children with problems such as: Congenital heart disease Cancers Tumors Hemophilia Sickle cell anemia Thyroid problems Diabetes Serious chronic kidney problems Liver disease Intestinal disease Cleft lip/palate Spina bifida Hearing loss Cataracts Cerebral palsy Seizures that are not controlled Rheumatoid arthritis Muscular dystrophy AIDS Severe head, brain or spinal cord injuries Severe burns Severely crooked teeth The state pays for CCS services. If your child is not eligible for CCS program services, he or she will keep getting medically necessary care from ADP. To learn more about CCS, call (TTY ).

28 Page 28 of 48 Coordination of benefits ADP offers services to help you coordinate your dental care needs at no cost to you. If you have questions or concerns about your dental care or the dental care of your child, call (TTY ). 9. Rights and responsibilities As a member of ADP, you have certain rights and responsibilities. This chapter will explain those rights and responsibilities. This chapter will also provide legal notices that you have a right to as a member of ADP. Your rights ADP members have these rights: To be treated with respect, giving due consideration to the member s right to privacy and the need to maintain confidentiality of the member s medical and dental information. To be provided with information about the plan and its services, including covered services. To be able to choose a Primary Care Dentist within the Contractor s network. To participate in decision making regarding their own dental care, including the right to refuse treatment. To voice grievances, either verbally or in writing, about the organization or the care received. To receive oral interpretation services for their language. To have access to Federally Qualified Health Centers, Indian Health Service Facilities, and emergency services outside the Contractor s network pursuant to the federal law. To request a State Hearing, including information on the circumstances under which an expedited hearing is possible. To have access to, and where legally appropriate, receive copies of, amend or correct their dental record. To disenroll upon request. To receive written member informing materials in alternative formats (including Braille, large size print, and audio format) upon request and in a timely fashion appropriate for the format being requested and in accordance with W & I Code Section (b)(12).

29 Page 29 of 48 To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. To receive information on available treatment options and alternatives, presented in a manner appropriate to the Member s condition and ability to understand. To receive a copy of his or her dental records, and request that they be amended or corrected, as specified in federal regulations. Freedom to exercise these rights without adversely affecting how they are treated by the Contractor, providers, or the State. Your responsibilities ADP members have these responsibilities: Give your dentist and ADP correct information. Understand your dental problem(s) and help in making treatment goals, as much as possible, with your dentist. Always present your member identification card when getting services. Ask questions about any dental condition. Make certain that you understand the information. Make and keep dental appointments. Let your dentist know at least 24 hours in advance when an appointment must be cancelled. Help ADP keep accurate and current medical records. Tell us as soon as you can of changes to your information. Including changes in address, family status, and other health care coverage. Notify ADP as soon as possible if a dentist bills you wrongly. Notify us if you have a complaint. Be courteous and respectful to all ADP staff and providers. Notice of Privacy Practices A statement describing ADP policies and procedures for preserving the confidentiality of dental records is available and will be furnished to you upon request. Since Access Dental Plan is a part of the Guardian Family, you will receive two privacy notices. THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective: 05/01/2016 This Notice of Privacy Practices describes how Access Dental Plan and its subsidiaries may use and disclose your Protected Health Information (PHI) in order to carry out

30 Page 30 of 48 treatment, payment and health care operations and for other purposes permitted or required by law. Access Dental Plan is required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices concerning PHI. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all PHI maintained by us. If we make material changes to our privacy practices, copies of revised notices will be made available on request and circulated as required by law. Copies of our current Notice may be obtained by contacting Access Dental Plan (using the information supplied below), or on our Web site at What is Protected Health Information (PHI): PHI is individually identifiable information (including demographic information) relating to your health, to the health care provided to you or to payment for health care. PHI refers particularly to information acquired or maintained by us as a result of your having health coverage (including medical, dental, vision and long term care coverage). In What Ways May Access Dental Plan Use and Disclose your Protected Health Information (PHI): Access Dental Plan has the right to use or disclose your PHI without your written authorization to assist in your treatment, to facilitate payment and for health care operations purposes. There are certain circumstances where we are required by law to use or disclose your PHI. And there are other purposes, listed below, where we are permitted to use or disclose your PHI without further authorization from you. Please note that examples are provided for illustrative purposes only and are not intended to indicate every use or disclosure that may be made for a particular purpose. Access Dental Plan has the right to use or disclose your PHI for the following purposes: Treatment. Access Dental Plan may use and disclose your PHI to assist your health care providers in your diagnosis and treatment. For example, we may disclose your PHI to providers to supply information about alternative treatments. Payment. Access Dental Plan may use and disclose your PHI in order to pay for the services and resources you may receive. For example, we may disclose your PHI for payment purposes to a health care provider or a health plan. Such purposes may include: ascertaining your range of benefits; certifying that you received treatment; and requesting details regarding your treatment to determine if your benefits will cover or pay for your treatment.

31 Page 31 of 48 Health Care Operations. Access Dental Plan may use and disclose your PHI to perform health care operations, such as administrative or business functions. For example, we may use your PHI for underwriting and premium rating purposes. However, we will not use or disclose your genetic information for underwriting purposes and are prohibited by law from doing so. Appointment Reminders. Access Dental Plan may use and disclose your PHI to contact you and remind you of appointments. Health Related Benefits and Services. Access Dental Plan may use and disclose PHI to inform you of health related benefits or services that may be of interest to you. Plan Sponsors. Access Dental Plan may use or disclose PHI to the plan sponsor of your group health plan to permit the plan sponsor to perform plan administration functions. For example, a plan may contact us regarding benefits, service or coverage issues. We may also disclose summary health information about the enrollees in your group health plan to the plan sponsor so that the sponsor can obtain premium bids for health insurance coverage, or to decide whether to modify, amend or terminate your group health plan. Access Dental Plan is required to use or disclose your PHI: To you or your personal representative (someone with the legal right to make health care decisions for you); To the Secretary of the Department of Health and Human Services, when conducting a compliance investigation, review or enforcement action related to health information privacy or security; and Where otherwise required by law. Access Dental Plan is Required to Notify You of any Breaches of Your Unsecured PHI. Although Access Dental Plan takes reasonable, industry-standard measures to protect your PHI, should a breach occur, Access Dental Plan is required by law to notify affected individuals. Under federal medical privacy law, a breach means the acquisition, access, use, or disclosure of unsecured PHI in a manner not permitted by law that compromises the security or privacy of the PHI. Other Uses and Disclosures. Access Dental Plan may also use and disclose your PHI for the following purposes without your authorization: We may disclose your PHI to persons involved in your care or payment for care, such as a family member or close personal friend, when you are present and do not object, when you are incapacitated, under certain circumstances during an emergency or when otherwise permitted by law.

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