THE SMILECARD PLAN
CERTIFICATE OF MEMBERSHIP
The SmileCard Plan (SmileCard) is a discount medical plan and is not insurance. SmileCard provides discounts at certain dental providers for dental services. SmileCard does not make payments directly to providers of dental services. The SmileCard member is obligated to pay for all dental services but will receive a discount from providers who have contracted with Argus Dental & Vision, Inc. (Argus). Argus is a Discount Medical Plan Organization licensed under Florida Statutes, Chapter 636. Argus is located at 4010 West State Street, Tampa, FL 33609.
PART I: AGREEMENT
This Certificate of Membership (Certificate) between Argus and [______] (Subscriber) is effective on the first (1st) day of ______, 20___ (Effective Date).
This Certificate provides a detailed summary of SmileCard, along with your rights and benefits as a Member. The SmileCard Enrollment Application, Member Guide, and Certificate of Membership constitute the entire agreement between the Subscriber and Argus. No agent may change the agreement or waive any of the provisions.
PART II: DEFINITIONS
Dependent– An eligible family member of a Subscriber who is enrolled in SmileCard.
Discounted Service Fee– The amount listed in the Member Guide for discounted services that the Member is required to pay at the time of treatment.
Member Guide– A document which contains a description of services offered through SmileCard when using a Participating General Dentist or Participating Specialist, the Discounted Service Fees that can be charged to a Member for the services, and the Member’s rights and responsibilities.
Identification Card– The proof of membership in SmileCard, which has the Member’s name.
Medically Necessary– Services that are necessary and meet professionally recognized standards of practice. The fact that a dentist may prescribe, order, recommend, or approve a service or material does not in itself make it medically necessary, or make it a service or material offered through membership even though it is not listed as an exclusion in the Member Guide.
Member– An individual enrolled in SmileCard.
Non-Participating General Dentist– A general dentist who has not agreed to provide dental services under the terms and conditions of SmileCard.
Non-Participating Specialist– A dental specialist who has not agreed to provide dental services under the terms and conditions of SmileCard.
Participating General Dentist– A SmileCard contracted dentist who agrees to provide discounted services to SmileCard Members. Participating General Dentists are also referred to as Contracted Dentists.
Participating Specialist– A SmileCard contracted dental specialist who agrees to provide discounted services to SmileCard Members. Specialists include Endodontists, Periodontists, Oral Surgeons, Pediatric Dentists, Orthodontists, and Prosthodontists. Participating Specialists are also referred to as Contracted Specialists.
Plan– The SmileCard Discount Dental Plan, which offers access to discounted dental care when utilizing a Participating General Dentist or Participating Specialist.
Subscriber– The person who represents the family unit in relation to the dental benefit program.
PART III: WHO MAY ENROLL
You may enroll yourself and your Dependent(s), provided each Dependent meets the Dependent Membership requirements listed below.
PART IV: DEPENDENT MEMBERSHIP
Eligible Dependents are defined as:
· Subscriber’s lawful spouse;
· Subscriber’s unmarried children or grandchildren up to age twenty-six (26) for whom Subscriber provides care, including adopted children, step-children, or other children for whom Subscriber is required to provide dental care pursuant to a court or administrative order; and
· Subscriber’s children who are incapable of self-sustaining employment and support due to a developmental disability or physical handicap.
PART V: WHEN MEMBERSHIP BEGINS
Membership for Subscriber and Dependent(s) will begin on the Effective Date listed above in Part I: Agreement.
PART VI: ENROLLMENT OF NEWLY ELIGIBLE DEPENDENTS
To enroll a newly eligible Dependent under a Subscriber’s Plan, a Subscriber must notify the Plan in writing and provide documentation of the new relationship, as indicated below:
A. Marriage: The Subscriber must submit notice and documentation to the Plan within thirty (30) days after the date of marriage.
B. Newborn: The Subscriber must submit notice and documentation to the Plan within thirty (30) days after the date of birth.
C. Adopted Child: The Subscriber must submit notice and documentation to the Plan within thirty (30) days after:
1. The date of filing a petition to adopt, if the child has been living in the Subscriber’s residence as a foster child for whom the Subscriber has received foster care payments;
2. The birth of a newborn child, if there is a written agreement in place to adopt the child; or
3. In all other cases, the date of the child’s placement in the Subscriber’s residence by a licensed placement agency for the purpose of adoption.
The newly eligible Dependent(s) enrollment will be processed by the Plan after receipt of the notice and documentation from the Subscriber. A newborn child will be eligible from the moment of birth. An adopted child will be eligible from the moment of placement in the residence of the Subscriber. For a newborn adopted child, membership will begin from the moment of birth if a written agreement to adopt such child has been entered into by the Subscriber prior to the birth of the child whether or not such agreement is enforceable. However, membership for such child is not required if the child is not ultimately adopted by the Subscriber. All other Dependents who become eligible after the effective date of the Subscriber shall become members on or before the thirtieth (30th) day following processing of the notice by the Plan.
PART VII: CHOICE OF PROVIDER
When Subscriber enrolls in the Plan, Subscriber and each Dependent may access care through any Participating General Dentist or Participating Specialist. Please refer to the Directory of Participating Dentists, which can be found on the Plan’s website at www.argusdentalvision.com, for a complete listing of Participating General Dentists and Participating Specialists.
PART VIII: MAKING AN APPOINTMENT
Once membership begins, Subscriber may contact a Participating General Dentist or Participating Specialist to schedule an appointment. SmileCard Participating General Dentists and Participating Specialists are available in accordance with their individual practice policies. When scheduling an appointment, Subscriber shall identify himself/herself as a SmileCard Member. Subscriber’s selected Participating General Dentist or Participating Specialist will also need to know Subscriber’s primary dental concern(s) and basic personal information.
Subscriber should arrive early for the first appointment to complete any paperwork.
The Plan recommends that Subscriber takes the Identification Card to the appointment, along with the Member Guide for the Discounted Service Fees. Please remember, only eligible dental services that are provided by a SmileCard Participating General Dentist and Participating Specialist are offered at a discount.
PART IX: SPECIALTY CARE
During the course of treatment, Subscriber’s Participating General Dentist may encounter situations that require the services of a provider whose practice is limited to specialty care, as defined herein. Services provided by a Participating Specialist are available at a twenty-five percent (25%) discount off their customary charges. Payment for care provided by a Non-Participating Specialist is the sole responsibility of the Subscriber.
PART X: CHANGING YOUR DENTIST
Subscriber has control over choice of dental offices and can make changes at any time. Subscriber must pay all outstanding charges owed to Subscriber’s current Participating General Dentist or Participating Specialist before transferring to a new Participating General Dentist or Participating Specialist. In addition, Subscriber is responsible for payment of all fees and costs associated with duplicating x-rays and dental records.
PART XI: MEMBERSHIP FEES
The Subscriber has elected to pay monthly payments or a one-time annual payment for SmileCard membership as chosen below. The total membership fee for Subscriber will include the following:
Description / Monthly * / AnnualMembership Fee / [$8.95] / [$107.40]
One-Time Enrollment Fee / $25.00 / $25.00
Monthly Service Charge / $ 1.00 / N/A
Total Payment Due* / [$34.95] / [$132.40]
*If the Subscriber elected monthly billing, the Subscriber’s account will be debited or charged by the fifteenth (15th) day of each month for the next month’s membership fee. A one dollar ($1.00) service charge will also apply for monthly billing.
All membership fees must be received by the Plan no later than the close of business on the fifteenth (15th) day of the month preceding the month of membership. Payments must be mailed to Argus Dental & Vision, Inc., 4010 W. State St., Tampa, FL 33609. If any required membership fee is not paid on or before the due date, it may be subject to cancellation as stated in Part XVII: Cancellation of Benefits.
PART XII: SMILECARD SERVICES
When Subscriber receives care from a Participating General Dentist or Participating Specialist, Subscriber will pay the Discounted Service Fee found within the Member Guide. If Subscriber chooses to receive services from a Non-Participating General Dentist or Non-Participating Specialist, Subscriber will be liable to the Non-Participating General Dentist or Non-Participating Specialist for the entire cost of the charges billed.
PART XIII: MEMBER SERVICES
SmileCard provides toll-free access to the Plan’s Member Services Department to assist Members with membership questions or problem resolution. SmileCard’s Member Services Department can be reached Monday through Friday at (877) 864-0625, from 8:00am-8:00pm EST.
PART XIV: GRIEVANCE PROCEDURES
Informal Grievance
Any Member who has a grievance against SmileCard for any matter arising from a Subscriber Certificate or for covered services rendered hereunder may submit an informal oral grievance to the Plan. Assistance with the Plan’s grievance procedures, including assistance with informal oral grievances, may be obtained by calling the Plan’s Member Services Department at (877) 864-0625. Oral grievances shall be submitted to Plan’s Grievance & Appeals Department. Informal oral grievances shall be responded to as soon as possible by the Grievance Coordinator. If the informal oral grievance involves a medical-related matter or claim, a dentist shall be involved in resolving said grievance. The Member has the right to file a formal written grievance with the Plan.
Formal Grievance
If the Subscriber or Dependent(s) has a grievance with SmileCard, the Participating General Dentist, or Participating Specialist, Subscriber may submit a written summary of the grievance to Argus Dental & Vision, Inc. at the address contain herein. A grievance is not considered formal until the Plan receives a written summary from the Subscriber. Subscriber’s written summary must be specifically identified as a grievance by the Subscriber and shall:
1. Be submitted within sixty (60) days from the date of the occurrence upon which the grievance is based;
2. Contain the statement of action requested by the Subscriber;
3. Include the Subscriber’s name, address, telephone number, member number;
4. Contain the name of the Subscriber’s Participating General Dentist or Participating Specialist;
5. Subscriber’s signature and the date.
The Plan agrees to duly investigate and resolve any and all complaints and grievances received from Subscriber regarding the Plan.
The Plan will confirm receipt of Subscriber’s grievance, in writing, within five (5) business days. The Plan will resolve the grievance and communicate the resolution, in writing, within thirty (30) days. The timeframe may be extended up to thirty (30) days if the Subscriber asks for an extension or the Plan documents that additional information is needed and the delay is in the Subscriber’s interest.
Expedited Grievance
The Plan will confirm receipt of the Subscriber’s expedited grievance, orally, within twenty-four (24) hours. The Plan will resolve the expedited grievance within seventy-two (72) hours and will communicate the resolution orally and in writing to the Subscriber.
PART XV: APPEALS
If the action taken by the Plan is not satisfactory to the Subscriber, the Subscriber may appeal the matter to the Plan within thirty (30) days after receiving notice of the resolution. The Subscriber’s request for an appeal must be submitted to the Plan, in writing, and should be directed to Argus Dental & Vision, Inc., Grievance Department, 4010 W. State St., Tampa, FL 33609. The Plan will resolve all appeals and communicate resolution, in writing, within thirty (30) days.
PART XVI: TERM OF AGREEMENT AND RENEWAL
The term of this SmileCard Certificate shall commence on the Effective Date and, unless sooner terminated as provided herein, shall continue in effect for an initial term of one (1) year (Initial Term). If Subscriber has elected monthly billing, this Certificate will automatically renew for successive terms (Renewal Term) until notice is given by either party. If Subscriber has elected the one-time annual payment option, Subscriber will receive a notice of renewal forty-five (45) days prior to the end of the Initial Term. Subscriber has the option to choose monthly payment, one-time annual payment, or cancellation. The terms of this Certificate will continue for successive terms (Renewal Term) regardless of payment option chosen until notice is given by either party.
A requested voluntary cancellation before the end of the Initial Term, and any subsequent Renewal Term, may result in a charge to the Member by the Participating General Dentist or Participating Specialist for the difference between the SmileCard Discounted Service Fee listed in the Member Guide and the Participating General Dentist or Participating Specialist’s customary charges. Refunds will be prorated and are subject to a twenty-five dollar ($25) administration charge. All requests for SmileCard cancellation must be submitted in writing to the Plan with a minimum of thirty (30) days advance notice.
All notices should be sent via U.S. Mail or email to either of the below addresses and include Subscriber’s ID number and the reason for cancellation:
U.S. Mail Email
4010 West State Street
Tampa, FL 33609
It is specifically understood that membership fee(s), the Discounted Service Fees, and other terms of SmileCard may be changed by the Plan. The Plan agrees to notify Subscriber, in writing, of the nature and extent of such changes forty-five (45) days prior to the effective date of such changes.
PART XVII: CANCELLATION OF BENEFITS
If the Subscriber cancels his or her membership in the Plan within the first thirty (30) days after the effective date of enrollment in the Plan, the Subscriber shall receive a reimbursement of all periodic charges, with the exception of the one-time enrollment fee of twenty-five dollars ($25).
The Plan may cancel the Subscriber’s membership after thirty (30) days written notice for the following: