San Francisco IHSS Public Authority
LIBERTY Dental Plan of California, Inc.
COMPARISON OF BENEFITS
EPO PLAN LDP100 PLAN
WHO IS COVERED? IHSS Worker Only IHSS Worker, Spouse, and/or
Child(ren)
TYPE OF PLAN PREFERRED PROVIDER OPTION
EPO Plan allows you to pick from a large network of
dentists. Also allows you to obtain services from an
out-of-network dentist. Plan covers 80% or more of
the allowable fee for most services.
MANAGED CARE OPTION
LDP100 provides services through a smaller group of
dentists with no member co-payment for most
services.
DEPENDENT COVERAGE NO YES
MONTHLY PREMIUM
CONTRIBUTION
(Per Month)
$ 2
Employee Only: $1
Employee + 1 dependent: $2
Employee + 2 or more dependents: $3
WAITING PERIODS Must be enrolled in the EPO Plan for 12
months before coverage for Major
Services begins.
None
COVERAGE PLAN PAYS
In EPO Out-of-
Network Network
MEMBER PAYS
Diagnostic &
Preventive
Exams, X-rays,
Prophylaxis,
Fluoride
100%
100% of EPO
Schedule
Deductible Applies
$0
Basic Fillings, Simple
Extractions 85%
85% of EPO
Schedule
Deductible Applies
$0
Major Oral Surgery,
Endodontics,
Periodontics,
*Crowns, *Bridges,
Partials, Denture
80%
12-month Waiting
Period Applies
80% of EPO
Schedule
Deductible Applies
12-month Waiting
Period Applies
$0
Orthodontics
Not Covered Not Covered
Children to age 19 - $1,550
Adults - $1,695
Start Up Fee - $175
Calendar Year
Deductible $0 $25 per member $0
Calendar Year
Maximum
Benefits
$1,000 per member None
* Base metal is the benefit. Noble, high noble, and titanium metal, if used, are considered upgraded treatments. The additional cost
of the upgraded treatment will be chargeable to the member.
EPO Plan: You are free to choose any dentist for treatment, but it is to your advantage to choose a First Dental Health EPO
dentist. This is because his or her fees are approved in advance by First Dental Health. First Dental Health EPO providers have
agreed to a pre-negotiated amount per covered procedure. The only amount chargeable to the member by an in-network provider
is the actual member percentage (based on the Plan) of the pre-negotiated amount, non-covered services, upgraded services, and
any amount over the annual maximum. Out-of-network providers have no agreement, so the amount chargeable to the member
can be any amount over the percentage payable by the Plan. Plan payment is based on the EPO pre-negotiated amount.
LDP100 Plan: You must choose a LDP100 participating Primary Care Dentist at the point of enrollment. If you do not choose a
Primary Care Dentist, one will be selected for you. If you wish to change to another participating LDP100 Primary Care Dentist at any
time, you must contact LIBERTY Dental Plan by the 20
th
day of the month for the change to be effective the first day of the following
month. LIBERTY Dental Plan will arrange for you to receive services from a contracted Dental Specialist if the necessary treatment
is outside the scope of General Dentistry. Your Primary Care Dentist will initiate the referral process with LIBERTY Dental Plan.
The proper referral process must be utilized for specialty services to be covered under the LDP100 Plan.
This is only a brief summary of the dental benefit plans. Please review the Evidence of Coverage and Benefit Schedule
(LDP100) and the Summary of Benefits (EPO) for complete benefit information.
