A. Enrollment and Eligibility
You and your dependents, including children through 25 years of age and your spouse or domestic partner.
B. Your Effective Date
If your application and payment information is submitted by the last day of the month, your coverage will be effective on the 1st of the following month. If it is submitted after the last day of the month, your coverage will be effective on the 1st of the second following month. A security deposit in the amount of 1 month of premium will be required upon sign up.
C. How does the SmartSmile plan work?
The SmartSmile dental plan provides a network of privately owned neighborhood dental offices to deliver high quality dental care to you and your family. You select a conveniently located participating dentist. During your first appointment, he or she will assess your oral health and outline your treatment plan. Your care then proceeds according to your plan. Most procedures require a copayment.
D. Annual Deductible & Calendar Year Maximums
One of the biggest advantages of Dental Health Services’ SmartSmile plan is that you have NO DEDUCTIBLES OR YEARLY COVERAGE MAXIMUMS. Instead, all covered dental treatments have a specific copayment.
E. Choice of Provider
SmartSmile members may choose any of the conveniently located dental offices from your Dental Health Services Directory of Participating Dentists. All dental care must be rendered by your selected dentist, except in the case of an out-of area emergency. You may change your dentist by calling your Member Service Specialist.
F. Emergency Dental Services
If you experience a dental emergency, you must first contact your selected dentist. If you can’t reach the office or if you are more than 50 miles from your selected dentist, you may be reimbursed up to $50 for emergency relief of pain, swelling and bleeding (palliative care) minus your applicable copayment. Contact your Member Service Specialist for assistance.
G. Coordination of Benefits
Dental Health Services is available as primary coverage and does not coordinate coverage with other dental benefits, if you have them.
H. Cancellation Policy
SmartSmile membership is for a period of one year. If you have selected to pay monthly, your membership will automatically renew. You must notify Dental Health Services in writing if you wish to cancel your coverage upon completion of your year-long membership. If you pay annually, you will receive a renewal notice prior to the end of your coverage. Dental Health Services reserves the right to change premiums or other plan contract provisions upon renewal. If you cancel your membership within your first year of coverage, you will be subject to a $50 cancellation fee to cover the administrative costs of the cancellation process. Any unearned premiums, less any cancellation fees will be refunded within 30 days if applicable. Cancellations must be received in writing and must be signed by the subscriber. Cancellation requests received by the 15th of the current month will be effective the first of the next month. Requests received on or after the 16th of the current month will be cancelled effective the first of the following month.
I. Termination of Policy
You must notify Dental Health Services in writing if you wish to cancel your coverage upon completion of your year-long membership. You may terminate your coverage by not renewing your membership. Dental Health Services may terminate your coverage for failure to pay premiums when due, material misrepresentation in obtaining coverage, or fraudulently permitting another person not covered under your plan to use your Dental Health Services’ membership card. Coverage for a subscriber and his or her dependants will terminate at the end of the month during which the subscriber ceases to be eligible for membership. In the event coverage is terminated, the member will become liable for charges resulting from treatment received after termination.
The following services are not covered by your dental plan
- Services that are not consistent with professionally recognized standards of practice.
- Cosmetic services, for appearance only, unless specifically listed.
- Myofunctional therapy-procedures for training, treating or developing muscles in and around the jaw or mouth including T.M.J. and related diseases, except for occlusal guard.
- Treatment for malignancies, neoplasms (tumors) and cysts as well as hereditary, congenital and/or developmental malformations.
- Dispensing of drugs not normally supplied in a dental office.
- Hospitalization charges, dental procedures or services rendered while patient is hospitalized.
- Procedures, appliances or restorations (other than fillings) that are necessary for full mouth rehabilitation, to increase arch vertical dimension, or crown/bridgework requiring more than 10 crowns/pontics. Replacement or stabilization of tooth structure lost through attrition, abrasion or erosion. Procedures performed by a prosthodontist.
- Fixed bridges for patients under the age of sixteen, in the presence of non-supportive periodontal tissue, when edentulous spaces are bilateral in the same arch, when replacement of more than four teeth in an arch, replacement of missing third molars, or when the prognosis is poor.
- General anesthesia, including intravenous and inhalation sedation.
- Dental procedures that cannot be performed in the dental office due to the general health and/or physical limitations of the member.
- Expenses incurred for dental procedures initiated prior to member’s eligibility with Dental Health Services, or after termination of eligibility.
- Services that are reimbursed by a third party (such as the medical portion of an insurance/health plan or any other third party indemnification).
- Extractions of non-pathologic, asymptomatic teeth, including extractions and/or surgical procedures for orthodontic reasons.
- Setting of a fracture or dislocation, surgical procedures related to cleft palate, micrognathia or macrognathia, and surgical grafting procedures.
- Coordination of benefits with another prepaid managed care dental plan.
- Orthodontic treatment of a case in progress and/or retreatment of ortho cases.
- Cephalometric x-rays, tracings, photographs and orthodontic study models.
- Replacement of lost or broken orthodontic appliances.
- Changes in orthodontic treatment necessitated by an accident of any kind.
- Malocclusions so severe or mutilated which are not amenable to ideal orthodontic therapy.
- Services not specifically covered on the Schedule of Covered Services and Copayments.
- Specialty services.
Restrictions on benefits are applied to the following services
- Treatment of dental emergencies is limited to treatment that will alleviate acute symptoms and does not cover definitive restorative treatment including, but not limited to root canal treatment and crowns.
- Optional services: when the patient selects a plan of treatment that is considered optional or unnecessary by the attending dentist, the additional cost is the responsibility of the patient.
- Routine teeth cleaning (prophylaxis) is limited to once every six months and full mouth x-rays are limited to one set every three years if needed.
- Periodontal surgical procedures are limited to four quadrants every two years.
- There are additional charges for precious/noble metals (gold).
- Replacement will be made of any existing appliance (denture, etc.) only if it is unsatisfactory and cannot be made satisfactory. Prosthetic appliances will be replaced only after five years have elapsed from the time of delivery. Lost or stolen removable appliances are the responsibility of the enrollee.
- Relines are limited to once per twelve months, per appliance.
- Single unit inlays and crowns are a benefit as provided above only when the teeth cannot be adequately restored with other restorative materials.
- The maximum benefit for pedodontic specialty care is $500 per lifetime.
Enrollees should refer to the Group Service Agreement for
further information on benefit exclusions and limitations.
- Retreatment of orthodontic cases.
- Treatment of a case in progress at inception of eligibility.
- Surgical procedures (including extraction of teeth) incidental orthodontic treatment.
- Surgical procedures related to cleft palate, micrognathia or macrognathia.
- Treatment related to temporomandibular joint (TMJ) disturbances and/ or hormonal imbalances.
- Any dental procedure considered within the field of general dentistry including but not limited to: myofunctional therapy; general anesthetics, including intravenous and inhalation sedation dental services of any nature performed in a hospital.
The following are subject to additional charges:
- Cephalometric x-rays, dental x-rays.
- Tracings and photographs.
- Study models.
- Replacement of lost or broken appliances.
- Changes in treatment necessitated by an accident of any kind.
- Services which are compensable under worker’s compensation or employer liability laws.
- Malocclusions so severe or mutilated they are not amenable to ideal orthodontic therapy.
- Full banded treatments are based on a 24-month standard treatment plan. Additional treatment, or treatment that extends beyond that time may be subject to additional charges.
If the contract between the group and Dental Health Services is terminated, service is subject to a pro-rated fee based on current market value for the balance of orthodontic treatment. If the member should terminate group coverage, they are no longer eligible for the group orthodontic rate.
Should the contract between Dental Health Services and the orthodontist terminate, any Dental Health Services members in treatment would not be subject to proration.
K. Grievance Procedures
First, discuss any grievance with your dentist. You may call your Member Service Specialist for assistance. Dental Health Services makes every effort to resolve grievances within 30 days of receipt. Grievances involving emergency care are addressed immediately and responded to in writing within five days. If you are not satisfied with the decision, you may request a review by writing Dental Health Services. Appeals may include review by a Peer Review Committee. Voluntary mediation is available by submitting a request to Dental Health Services.