KAISER PERMANENTE HEALTHY SMILE CARD HOLDER AGREEMENT
By enrolling in or using the Kaiser Permanente Healthy Smile Dental Plan (“the Plan”), you (or your legal representative if you are
incapable of contracting) are agreeing to all of the terms of this Agreement.
This Plan is not insurance. It is a dental discount plan offered by Kaiser Foundation Health Plan of the Northwest (“Kaiser”) and
administered by Group Dental Service of Maryland, Inc. (GDS-MD).
The Plan currently includes most dental services that you receive from participating providers. When you receive any of these included
services from a participating provider, you will pay the amount on the Healthy Smile fee schedule for the provider’s region. If the
provider’s usual fee is lower than the fee schedule amount, you will pay the lower fee. To get a list of participating providers in any zip
code or to find out whether a service is included in the Plan or what the fee schedule amount is for an included service, call Customer
Care at 1-866-498-7909.
If you have dental insurance with Kaiser Foundation Health Plan of the Northwest, you cannot use your Healthy Smile Plan at Kaiser
Permanente dental offices.
Participating providers, services included in the Plan, and fee schedule amounts are subject to change at any time without notice. It is
your responsibility to verify with your provider that the provider is currently a participating provider, that the services you receive are
currently included in the Plan, and what the current fee schedule amounts are. If your provider is no longer a participating provider, you
will have to switch to a participating provider in order to use the Plan. Not all types of participating providers are available in all areas,
and some participating providers may not be accepting new patients.
You are responsible for paying providers for any services you receive. The Plan does not make payments to providers or to you. You
cannot use the Plan for any services you receive from non-participating providers.
Participating providers are solely responsible for the services they provide, and GDS-MD and Kaiser disclaim any liability with respect
to these services.
Annual Cost to Enroll in Kaiser Permanente Healthy Smile Dental Plan:
- $98 per year Family
- $150 per year
A family plan can include up to a total of 9 people who either share the same primary residence or are college students. You cannot
enroll or remain enrolled in the Plan if you live in, or move to, Montana. To make additions or deletions to your plan, please call
customer care at 1-866-498-7909.
Term and Renewal: If your application is accepted, GDS-MD will mail you notice of your Plan effective date along with your ID card.
Your Program effective date will be the date that GDS-MD processes your application and your initial term will be one year from your
effective date. Before the end of the first year and each following year during which this Agreement is in effect, the Plan will mail you a
renewal notice explaining any changes to the Plan, including any changes in the cost to enroll for another year. Unless you cancel or
fail to pay for the new year, each year your Plan and this Agreement will automatically renew (with the changes explained in the
renewal notice) for one more year. If you paid previously with a credit card or electronic withdrawal from a bank account, your credit
card or bank account will be automatically charged or drafted for the appropriate renewal cost each time your Plan renews, unless you
send GDS-MD a letter withdrawing your authorization for these charges or drafts.
Termination: You have 30 days from your initial Plan effective date to use the Plan risk-free. If for any reason within those 30 days you
are dissatisfied with the Plan, you can cancel and get a refund of any money you paid to enroll in the Plan by mailing a cancellation
letter and a request for refund with your name and enrollee number to GDS-MD, Attn: Healthy Smile Dental Plan, 111 Rockville Pike,
Suite 700, Rockville, MD 20850. If you wish to cancel after the 30-day period, call Customer Care at 1-866-498-7909.
GDS-MD reserves the right to terminate your participation in the Plan for any reason, such as non-payment. If GDS-MD terminates
your participation in the Plan before the end of the year for which you enrolled, GDS-MD will send you a pro-rata refund of any money
you paid for the remaining portion of the year for which you enrolled (the portion after your termination date).
For Oklahoma residents only, if all of the periodic charges have not been refunded by GDS-MD within thirty (30) days, interest shall be
assessed and paid on the proceeds at a rate of the Treasury Bill rate of the preceding calendar year, plus two (2) percentage points.
Complaint Procedure: To file a complaint or grievance regarding the Plan, you must send a letter to: GDS-MD, Attn: Kaiser
Permanente Healthy Smile Plan, 111 Rockville Pike, Suite 700, Rockville, MD 20850.
Assignment: You may not assign this Agreement.
Entire Agreement: This Agreement is your entire agreement with Kaiser and GDS-MD concerning the Kaiser Permanente Healthy
Smile Dental Plan.
Disclosure: This Program is not insurance. It is a discount program. You are responsible for the full cost of any dental
care services purchased. You will receive discounts for dental services at certain dental care providers who have
contracted with the Program. Members have the right to cancel registration within a 30 day period. This Program does
not make payments directly to dental care providers. A list of all dental program providers within the prospective
cardholder’s geographic area which includes their name, city & state, and medical specialty is available prior to
purchase, upon request. Discounts for dental services received in a hospital are not included in this Program.
This Program is administered by Group Dental Service of Maryland, Inc. (GDS-MD), your Discount Medical Plan
Organization, 111 Rockville Pike, Suite 700, Rockville, MD 20850, 866-498-7909, www.kphealthysmile.org. The
Program and its administrators have no liability for providing or guaranteeing service or the quality of service rendered.