P.O. Box 26110

Santa Ana, CA 92799-6110

Phone: 888-703-6999

Fax: 833-250-1814

IMPORTANT BENEFIT INFORMATION

RE:

CMS - MEDICAID SECTION 1135 WAIVER

COVID-19 NATIONAL STATE OF EMERGENCY

LIBERTY Dental Plan (LIBERTY) is providing you this important notice on your Medicaid

benefits. Due to the recent COVID -19 outbreak, the Centers for Medicare and Medicaid Services

(CMS) have issued a Federal Section Waiver. This waiver provides Medicaid enrollees, additional

resources during this COVID-19 National State of Emergency.

What does this mean for you?

• Referrals and pre authorizations will not be required starting March 15, 2020, until the end

of the National State of Emergency. This means claims will not be denied due to lack of

referral or preauthorization. LIBERTY will still review for dental need.

• Out-of-network benefits will be allowed for the treatment of emergency conditions, such

as pain, swelling, bleeding, broken tooth/teeth, etc. starting March 15, 2020, until the end

of the National State of Emergency. This means claims for emergency dental treatment,

will not be denied as out-of-network. LIBERTY will still review for dental need.

• Tele-dentistry will be made available, so you can talk with a dentist from home using video,

phone, or text messaging. This means claims will not be denied for tele-dentistry service.

• Timeframe to file for a State Fair Hearing increased. This means that if the initial State Fair

Hearing filing deadlines take place during the National State of Emergency, you will be

allowed an additional 120 days, for a total of 240 days, to request a State Fair Hearing.

The following resources are available to you during this emergency period.

All States

https://www.medicaid.gov/resources-for-states/disaster-response-

toolkit/coronavirus-disease-2019-covid-19/index.html

All States

https://www.cms.gov/outreach-education/partner-resources/coronavirus-

covid-19-partner-toolkit

California

https://covid19.ca.gov/

California

http://www.cdph.ca.gov/covid19

LIBERTY is also available during this COVID-19 National State of Emergency. If you have any

questions, please contact us at 888-703-6999. We are here to help.

Sincerely,

LIBERTY Dental Plan