How Do You Receive Care?
Upon completion of processing you will receive a personal identification card. Simply call the office you selected for an appointment as you usually would. Present your Plan I.D. Card at the time of your appointment. There are no claim forms to fill out.

Choice of Provider
If no Dental Code Number or Vision Code Number is submitted in an application, EHIS Inc will assign one based on the address on the application. Should the need arise, members are allowed to transfer, with PLAN APPROVAL, to a new office by contacting the Plan. This transfer will become effective on the first day of the following month.

Can Your Children Also Be Insured?
Children are eligible up to age 19 and extended to age 23 if they are full time students and claimed by you for Federal Income Tax purposes.

Other Charges
The member is responsible for the copayments for services listed in the "Description of Benefits and Copayments." Services not listed will be billed to the member at the doctor's usual and customary fee. These fees must be paid directly to the office where the service was received.

Qualsight
The Qualsight program is not an insured benefit. Vision Plan of America makes access to the Qualsight Program available to its members for preferred pricing for LASIK surgery. Vision Plan of America makes no specific recommendations for or against the Program. All representatives are those of Qualsight. To Access Preferred Pricing, Call 877-507-4448 from 7am to 9pm (CST) Weekdays and from 10am to 5pm Saturdays or visit www.qualsight.us

Termination of Benefits

1. On the expiration date.
2. Upon the date of entry into full-time military service.
3. Upon dependent attaining age 19 or prior marriage. An unmarried child who is over 19 years, but less than 24 years, whose time is principally devoted to attending school, and who is dependent upon his parents for primary support is eligible to be covered.
4. The PLAN reserves the right, if after reasonable efforts to establish and maintain a satisfactory Provider/Patient relationship with any Member and is unable to do so, to terminate the rights of such Member and other members of his family under contract effective the last day of the month during which termination notice occurs.
5. In the event that fees or premiums are deliquent, services and benefits under the PLAN shall be terminated effective on the last day of the month during which the deliquency occurred.
6. Permitting or committing fraud. In the event of termination, the plan provider shall complete any treatment in progress. The Member is required to pay all fees and premiums.

Principal Exclusions and Limitations

1. Services which are provided without cost to the Member by any municipality, county or other subdivision.
2. Service to which the Member is entitled under any Worker's Compensation Law or Act. This exclusion does not apply to the MediCal Program.
3. Medical or surgical treatment of the eyes (Dilation, tests related to dilation and extended exams) including specialized visual fields.
4. Services that cannot be performed in the Participating Providers office for any reason including the general health of the patient.
5. Dentistry for cosmetic purposes unless listed as a benefit.
6. Dispensing of drugs.
7. General anesthesia.
8. Loss or theft of dentures or bridgework.
9. Temporomandibular joint (TMJ) syndrome.

Grievance Procedure
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-400-4VPA and use your health plan's grievance process before contacting the department. Utilizing the grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service of treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web Site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

General Disclosure
This disclosure form is only a summary of the plans. The plan contract must be consulted to determine the exact terms and conditions of coverage. A specimen copy of the contract is available upon request at the Plan's administrative office. Plan administered by Vision Plan of America & California Dental Network: 1-800-400-4VPA.

Super Smile Plus Plan Disclosure
This disclosure form is only a summary of the plan. The plan contract must be consulted to determine the exact terms and conditions of coverage. A specimen copy of the contract is available upon request at the Plan's administrative office. Plan administered by Vision Plan of America & Liberty Dental: 1-800-400-4VPA.

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