Discount Dental Plan Terms and Conditions

Colorado Alpha Discount Dental Plan Terms, Conditions, and Membership Agreement

---

By submitting the online membership application I signify, understand and agree:

1. A monthly administrative fee, $1.50, is included in the draft amount.
2. I hereby agree to remain in the Dental Plan a minimum of one year. Less than one year membership may result in my being billed from the Alpha Dental Plan provider the normal rates for dental services provided, minus payments for services rendered during the year.
3. That fee schedule rates from Alpha Dental Plan are available through the offices of participating general dentists only. I am aware that Dental Specialists are not available in all areas, and they apply a flat Discount for services. 
4. I will make all scheduled payments to the Alpha Dental Plan provider at the time services are rendered.
5. I know this is NOT insurance.
6. I have read all covered services, payment schedules, and exclusions offered by the Alpha Dental Plan.
7. I hold Beta Health Association, Inc. blameless for any harm or loss arising from services or omission of services by the providing dentist and his staff.
8. Beta Health Association, Inc. is the Administrator for the Alpha Dental Plan.
9. I understand that I am continuously signed up for this plan until I cancel my plan. To cancel I must notify Beta Health Association, Inc. in writing 30 days in advance and will be responsible for any insufficient charges.
10. Auto renewal/recurring payments will be setup on either your credit card or as an eCheck based on the rate, number of members, and payment frequency option you select, occurring on the 17th of the month prior to your renewal date.

Payment Periods and Billing

By submitting the online membership application, I authorize Beta Health Association, Inc. to charge my Credit Card or Checking account on 2/20/2019 for membership in the Alpha Dental Plan. I further authorize Beta Health Association, Inc. to charge my Credit Card or Checking account on the 17th of the month, monthly, quarterly, or annually based on my selections, for the amount of the membership fees until I cancel or change my membership. The company name shown on your account will be Dental Plan Membership or 800-807-0706.

Choice+ and Care Choice Discount Dental Plan Terms and Conditions

---

Renewal Conditions:

By joining a plan, you are authorizing Beta Health Association, Inc. to bill your credit card or checking account for the plan you have selected. This charge shall remain in force until you notify Beta Health Association, Inc. of request to cancel. By joining, you indicate you have read the terms and conditions of the plan. This plan will automatically renew at the end of your membership term on an annual basis, and your credit card or bank account will be automatically charged or drafted for the appropriate amount.

Termination Conditions:

Beta Health Association, Inc. and Careington International Corporation (Careington) reserves the right to terminate plan members from its plan for any reason, including non-payment.

Cancellation Conditions:

You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less the processing fee, if applicable. FL Residents: You have the right to cancel within 30 days after the effective date. If for any reason during this time period you are dissatisfied with the plan and wish to cancel and obtain a refund, you must submit a written cancellation request. Beta Health Association, Inc. will accept and cancel plan memberships at any time during the membership period and will cease collecting membership fees in a reasonable amount of time, but no later than 30 days after receiving a cancellation notice. Please send a cancellation letter and a request for refund with your name and member number to Beta Health Association, Inc., 6200 South Syracuse Way, Suite #460, Greenwood Village, CO 80111 or fax to: (303) 369-1051. You may also submit cancellation by email: cancel@betaplans.com. If Beta Health Association, Inc. is billing you quarterly, semi-annually or annually, Beta Health Association, Inc. will, in the event of cancellation of the membership by either party, make a pro-rata reimbursement of the periodic charges to the member.

Description of Services:

Please see our Dental plan web site for a specific description of the programs that you have purchased.

Limitations, Exclusions & Exceptions:

This program is a discount membership program offered by Careington. Careington is not a licensed insurer, health maintenance organization, or other underwriter of health care services. No portion of any provider's fees will be reimbursed or otherwise paid by Careington. Careington is not licensed to provide and does not provide medical services or items to individuals. You will receive discounts for medical services at certain health care providers who have contracted with the plan. You are obligated to pay for all health care services at the time of your appointment. Savings are based upon the provider's normal fees. Actual savings will vary depending upon location and specific services or products purchased. Please verify such services with each individual provider. The discounts contained herein may not be used in conjunction with any other discount plan or program. All listed or quoted prices are current prices by participating providers and subject to change without notice. Any procedures performed by a non-participating provider are not discounted. From time to time, certain providers may offer products or services to the general public at prices lower than the discounted prices available through this program. In such event, members will be charged the lowest price. Discounts on professional services are not available where prohibited by law. This plan does not discount all procedures. Providers are subject to change without notice and services may vary in some states. It is the member's responsibility to verify that the provider is a participant in the plan. At any time Careington may substitute a provider network at its sole discretion. Careington cannot guarantee the continued participation of any provider. If the provider leaves the plan, you will need to select another provider. Providers contracted by Careington are solely responsible for the professional advice and treatment rendered to members and Careington disclaims any liability with respect to such matters.

Complaint Procedure:

If you would like to file a complaint or grievance regarding your plan membership, you must submit your grievance in writing to: Careington International Corporation, P.O. Box 2568, Frisco, TX 75034. You have the right to request an appeal if you are dissatisfied with the complaint resolution. After completing the complaint resolution process and you remain dissatisfied, you may contact your state insurance department.

Disclosures:

THIS PLAN IS NOT INSURANCE and is not intended to replace health insurance. This plan does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.* The plan provides discounts at certain health care providers for medical services. The range of discounts will vary depending on the type of provider and service. The plan does not make payments directly to the providers of medical services. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization. You may access a list of participating health care providers at Dental plan web site. Upon request the plan will make available a written list of participating health care providers. You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee (nominal fee for MD residents is $5, AR and TN resident will be refunded processing fee). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.

This plan is not available in Vermont. This plan is not currently available in Washington. *Medicare statement applies to MD residents when pharmacy discounts are part of plan.

Dental And Vision Insurance Terms and Conditions

Authorization Agreement

Payment Options

I authorize Ameritas Life Insurance Corp. to initiate electronic debit entries to my account chosen above for payment of my insurance premium. I certify that I am an authorized user on the above listed account. I acknowledge that debits to my account for premium due will occur on a regular recurring basis based on the payment frequency indicated above until such time as coverage terminates or until I notify Ameritas to terminate these transactions. I understand that it may take up to two weeks to process a request to discontinue recurring payments. In order to make changes to this authorization (such as change in bank account, method of payment, or termination of payment) I must provide Ameritas at least two weeks notice in advance of the next scheduled payment date.

Payment Information:

Initial premium will be withdrawn within 3 days of your policies effective date, subsequent premiums are due on the day of the month in which the policy was effective.

For initial payments I acknowledge that Ameritas may debit my account upon acceptance and approval of my application. Based upon my authorization, Ameritas will process reoccurring payments on or within three business days of the date of the month in which my policy was first effective.

If any authorized payment is returned or dishonored by my bank, I acknowledge that I am responsible for any fees my bank may charge. I understand also that I may incur a return payment fee of $25 charged by Ameritas if the return is due to insufficient funds. I acknowledge that such a fee, if charged, may be automatically debited from my authorized account on the next payment date. I am responsible for remitting payment within the policy grace period. If payment is not received by Ameritas within the defined grace period I acknowledge that my coverage may be canceled in accordance with the terms of the insurance contract.

I also acknowledge that I have read the following information from Ameritas regarding this electronic signature.

I consent to receiving my Outline of Coverage where applicable, and any other plan information electronically and I electronically affirm of my consent to do so. I understand I need internet access and that I can withdraw my consent at any time per the notification instructions below, I understand I can receive any of the documents in paper form if I choose.

• I may return my policy within the right-to-cancel period as described in my policy;
• I acknowledge receipt of the Outline of Coverage (in states where required by law);
• I understand the policy I am applying for provides dental and (if chosen) vision benefits only and is not a Medicare supplement;
• I acknowledge that the agent of record, if applicable, is my insurance agent for purposes of the Ameritas Privacy Policy; and
• I understand that it is my responsibility to give notice to Ameritas of changes in my email address or any information above, as well as my status and my family's status that effect coverage, such as marriage, births, or death of someone covered under the policy. I will provide notice via email at cs@ameritas.com, fax at 402-309-2598 or in writing to Ameritas or its designee: PO Box 82607, Lincoln, NE 68501-2607.

You are encouraged to print a copy of your electronic forms to retain for your own records. The computer hardware and software necessary to access your electronic forms are a personal computer with a Windows or Macintosh operating system. You will be notified by mail if there is ever a change in the hardware or software requirements for accessing your electronic forms.

Dental Limitations and Exclusions

Limitations and Exclusions
Dental Expenses will not include, and benefits will not be payable, for any of the following.

• Covered Dental Expenses for appliances, restorations, or procedures to do any of the following.
  1. Alter vertical dimension.
  2. Restore or maintain occlusion.
  3. Splint or replace tooth structure lost as a result of abrasion or attrition.
• Covered Dental Expenses for any procedure begun after the insured person’s insurance under this contract terminates.
• Covered Dental Expenses to replace lost or stolen appliances.
• Covered Dental Expenses for any treatment which is for cosmetic purposes.
• Covered Dental Expenses for any procedure not shown in the Table of Dental Procedures. (Frequency and other limitations may apply. Please see the Table of Dental Procedures for details.)
• Covered Dental Expenses for orthodontic treatment unless orthodontic expense benefits have been included in this policy. Please refer to the Schedule of Benefits and Orthodontic Expense Benefits provision.
• Covered Dental Expenses for which the Insured person is entitled to benefits under any workers’ compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of employment.
• Covered Dental Expenses for charges which the Insured person is not liable or which would not have been made had no insurance been in force, except for those benefits paid under Medicaid.
• Covered Dental Expenses for services that are not required for necessary care and treatment or are not within the generally accepted parameters of care.
• Covered Dental Expenses because of war or any act of war, declared or not.
• Alternative Procedures – Occasionally two or more procedures are considered adequate and appropriate treatment to correct a certain condition under generally accepted standards of dental care. In this case, the amount of the Covered Expense will be equal to the charge for the least expensive procedure. This provision is NOT intended to dictate a course of treatment. This provision is designed to determine the amount of the plan allowance for a submitted treatment when an adequate and appropriate alternative procedure is available. You may choose to apply the alternate benefit amount determined under this provision toward payment of the received treatment.

Vision Limitations and Exclusions

VSP® Limitations
Please check for availability in your state. Based on applicable laws, reduced costs may vary by doctor locations. Covered expenses will not include and no benefits will be payable for:

• Vision examinations, lenses and frames more than the frequency as indicated on the plan summary page.
• Services and/or materials not specifically included in the Schedule as covered Plan Benefits.
• Plano lenses (lenses with refractive correction of less than plus or minus .50 diopter) except as specifically allowed in the frames benefit section of the Plan Benefits.
• Services or materials that are cosmetic, including plano contact lenses to change eye color and artistically painted contact lenses.
• Two pairs of glasses in lieu of bifocals.
• Replacement of spectacle lenses, frames, and/or contact lenses furnished under this plan that are lost or damaged, except at the normal intervals when services are otherwise available.
• Orthoptics or vision training and any associated supplemental testing.
• Medical or surgical treatment of the eyes.
• Contact lens modification, polishing or cleaning.
• The refitting of contact lenses after the initial 90-day filing period.
• Contact lens insurance policies or service contracts.
• Additional office visits associated with contact lens pathology.
• Local, state and/or federal taxes, except where law requires us to pay.
• Covered persons may be required to purchase a membership at certain retail locations before accessing plan benefits.

EyeMed Limitations
Please check for availability in your state. Based on applicable laws, reduced costs may vary by doctor locations. Covered expenses will not include and no benefits will be payable for:

• Vision examinations, lenses and frames more than the frequency as indicated on the plan summary page.
• Orthoptics or vision training and any associated supplemental testing.
• Plano lenses (lenses with refractive correction of less than plus or minus .50 diopter) except as specifically allowed in the frames benefit section of the Plan Benefits.
• Two pairs of glasses in lieu of bifocals.
• Replacement of spectacle lenses, frames, and/or contact lenses furnished under this plan that are lost or damaged, except at the normal intervals when services are otherwise available.
• Medical or surgical treatment of the eyes.

Non-network Limitations
Please check for availability in your state. Based on applicable laws, reduced costs may vary by doctor locations. Covered expenses will not include and no benefits will be payable for:

• Vision examinations, lenses and frames exceeding the set annual benefit amount.
• Examinations performed or frames or lenses ordered before the member was covered under the plan.
• Subject to extension of benefits, any examination performed or frame or lens ordered after the coverage under the plan ceases.
• Sub-normal eye care aids; orthoptic or eye care training or any associated testing.
• Non-prescription lenses.
• Any eye examination or corrective eyewear required by an employer as a condition of employment.
• Medical or surgical treatment of the eyes.
• Any service or supply not shown on the Schedule of Eye Care Procedures.
• Coated lenses; oversize lenses (exceeding 71 mm); photo-gray lenses; polished edges; UV-400 coating and facets, and tints other than solid.
• Claims filed more than 90 days after completion of the service (or longer than 90 days in certain states). An exception is if the Insured shows it was not possible to submit the proof of loss within this period.

Indemnity Vision Limitations:
Covered Expenses will not include and no benefits will be payable for expenses incurred for:

• Vision examinations more than once in any 12 month period.
• Prescribed lenses more than once in any 12 month period.
• Frames more than once in any 24 month period.
• Contact lenses more than once in any 12 month period. When chosen, contact lenses shall be in lieu of any other lenses benefit during the 12 month period and in lieu of any other frame benefit during the 24 month period. When lenses are chosen, expenses for contact lenses are not Covered Expenses during the 12 month period.
• Examinations performed or frames or lenses ordered before the Insured was covered under this section.
• Any examination performed or frame or lens ordered after the Insured’s coverage under this section ceases, subject to Extension of Benefits.
• Sub-normal vision aids; orthoptic or vision training or any associated testing.
• Non-prescription lenses.
• Replacement or repair of lost or broken lenses or frames except at normal intervals.
• Any eye examination or corrective eyewear required by an employer as a condition of employment.
• Medical or surgical treatment of the eyes.
• Any service or supply not shown on the Schedule of Eye Care Services.
• Coated lenses; oversize lenses (exceeding 71 mm); photo-gray lenses; polished edges; UV-400 coating and facets, and tints other than solid.

Important Fraud Notices

Review your policy carefully
In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (State-specific statements below.)