Modern Heritage Eye Care Members Only Optometric Savings Plan
Contract, Terms, and Conditions

This document serves as the Contract Description of the Terms and Conditions of the Optometric Savings Plan available to you and your family members through Modern Heritage Eye Care, LLC. This document thoroughly outlines the plan and your rights and responsibilities under the plan. By completing this document, you agree that this document will also serve as your contract with Modern Heritage Eye Care, LLC. It is your responsibility to read this contract in detail. IT IS YOUR RESPONSIBILITY TO BE AWARE OF AND UNDERSTAND THE FOLLOWING INFORMATION REGARDING FROM WHOM OR WHAT GROUP OF PROVIDERS OPTOMETRIC CARE CAN BE OBTAINED. If you have any questions about this contract, please call Modern Heritage Eye Care, LLC at (855) 643-2273.

1.     Contact Information: The full name of the plan is The Modern Heritage Eye Care Members Only Optometric Savings Plan (referred to hereafter as “MHSP”). MHSP has one location in which you may obtain services and materials under this plan.

Modern Heritage Eye Care, LLC

5150 Chappel Dr.

Perrysburg, OH 43551

P: 419-873-7446

Toll Free: (855) 643-2273
F: 844-464-7407

Email: membership@modernheritageeyecare.com

Website: www.modernheritageeyecare.com

 

 

2.     Type of Plan: This is a savings plan. THE SAVINGS PLAN IS NOT INSURANCE AND DOES NOT REPLACE ANY INSURANCE PLAN. By agreeing to and paying an annual membership fee to MHSP (see Section 9), you (and if applicable, your dependents) will be entitled to receive vision services and materials at cost saving rates.

 

3.     Definitions:
Eligibility: your or your dependents’ rights to receive vision services and materials at cost saving rates.
Dependents: include dependent children who are under age 18 or who, due to physical or mental disability, injury, illness, or other eligible conditions, are unable to self-sustain employment, and/or who are dependent solely on you for financial support, medical care, and maintenance.
Network Optometrist: an optometrist who has an agreement with MHSP to provide vision services and materials at the cost saving rates outlined in this contract.

4.     Choice of Optometrists: To be entitled to the cost saving rates, you and your dependents must visit a MHSP Network Optometrist. If you choose to receive vision services or materials from an eye care provider who is not in network with the MHSP, you will not be entitled to the cost saving fees provided by the plan. You may visit any Network Optometrist, including the Network Optometrists whose names and addresses are included in the MHSP brochure. If you have a question about MHSP’s Network Optometrists, please call Modern Heritage Eye Care, LLC at (855) 643-2273. 

5.     Eligibility Details: You may elect eligibility for yourself, for you and your spouse, or for you and all of your dependents.

 

6.     Commencement of Receipt of Services and Materials: Once you have read through this Contract you may complete and sign the Membership Application Form at the end of this document. The completed Membership Application Form must be mailed to MHSP at the address listed on the Membership Application Form along with your payment for the one-time processing fee and the initial annual membership fee. The Membership Application Form can be completed onsite at any of the network optometrist locations and turned in to a designated staff member. Annual membership fees can be made by debit or credit card. Once all Membership Application Forms and fees are received and processed, MHSP will send you and any enrolled dependents a membership identification card. Your membership identification card must be presented to your Network Optometrist at the beginning of each visit in order for you to receive vision services and materials unless you are applying for the MHSP in-office enrollment, at which time savings could be immediately applied.

 

7.     Term and Termination of Services: Your and your dependents’ rights to obtain vision services and materials will continue for one year from the time Modern Heritage Eye Care, LLC receives your initial membership fee and processing fees. Annual membership fees will be charged on an automatic renewal basis or until cancelled by the member.
Other Events that May Lead to Termination of Eligibility Before the Date of Automatic Renewal:

a.     Eligibility for any minor dependent will terminate on the child’s 18th birthday unless

                        i.     If upon reaching the age of 18 years, your child, due to physical or mental disability, injury, illness, or other eligible conditions, is unable to self-sustain employment, and/or is dependent solely on you for financial support, medical care, and maintenance, then eligibility for that child will continue through the term of your enrollment and membership. However, it is your responsibility to submit proof to MHSP of such incapacity and dependency at least sixty (60) days before your child’s eligibility will terminate. Failure to do so will result in your dependent losing eligibility.  MHSP will review the submitted documents determine if your child’s incapacity and dependency status qualifies him or her to maintain dependent status. MHSP will notify you before your child’s eligibility ends. If MHSP fails to notify you of its determination before your child’s 18th birthday, your child’s will remain eligible and will continue to receive services and materials at a cost savings rate until you receive such notice.

 

Your right to receive services at the cost saving rates outlined in this plan will auto-renew annually unless you choose to cancel as described in section 8. Upon termination of your membership, your Network Optometrist will complete all procedures started before termination at current rates.

 

8.     Membership Renewal: Your membership will automatically renew and your right to receive a savings on service and materials fees for an additional year will continue with the automatic payment of your annual membership fee to MHSP before your initial eligibility terminates. MHSP will send you an electronic notice about this at least thirty (30) days before the renewal of eligibility. Annual membership fees are subject to change and may differ from the initial annual membership fees described in Section 9. You will receive notice of any changes of applicable membership fees in your renewal notice. You and your eligible dependents’ identification cards will remain valid. The same procedure will be used to re-enroll for succeeding years. Other than payment of the required annual membership fee, there are no other conditions or restrictions on your ability for continued membership enrollment.

 

Cancellation of Membership: You will have thirty (30) days after your fees are paid to cancel your eligibility and receive a full refund of your membership fee. To receive your refund, you must submit a written request for the cancellation and refund. The refund will not include the processing fee, any fees for services rendered, or glasses/contact lens orders that have been processed.

 

You can terminate your eligibility at any time by delivering by hand, sending by mail, or e-mailing a written notice of cancellation. If you choose to cancel your membership after 30 days, you will not receive any refunds or membership fees, processing fees, or fees paid for services or materials rendered. MHSP reserves the right to cancel your membership or refuse to permit you from re-enrolling at any time, for cause. A pro rata reimbursement of your membership fee will be refunded to you provided that there has been no failure to pay fees by the member. Processing fees and fees paid for services rendered will not be refunded.  However, if you believe that MHSP has canceled your membership or refused your membership because of you or any eligible dependents’ health status, you may contact the Ohio Department of Insurance at 800-686-1526 or contact the Department via mail at

Ohio Department of Insurance
50 W. Town Street
Third Floor – Suite 300
Columbus, Ohio 43215.

9.     Processing and Membership Fees: Upon enrollment, initial Membership fees and a one-time processing fee of $30.00 will be due. Membership fees may be paid on an annual or monthly basis. Payment of the one-time processing fee and membership fees must be made by debit or credit card. Family members may be added at any time. Each family member must complete their own service agreement and disclosure form.  Each adult patient will be assessed their own membership fee. Children’s membership fees are only free with a paid adult membership. Only one free membership per child per year is permitted. Parents/guardians must complete a service agreement and disclosure form for each minor enrolled. Annual membership fees are subject to change.

 

10.  Optometric Services and Fees: MHSP reserves the right to change the fee schedule at any time, and any new fee schedule will apply to all optometric services received by you or your family members.

 

11.  Other Charges: There are no other charges of any kind under this plan. You are responsible for paying for vision services rendered and materials ordered at this time of services.

 

12.  Limitations and Excluded Services: The following is a complete list of all limitations and excluded services under this Savings Plan:

Comprehensive Annual Eye Exam

Once every 12 months

Contact Lens Examination (Annual Re-evaluation)

Once every 12 months

Refraction

Once every 12 months

Contact Lens Fittings and Classes

As needed

Prescription Glasses (Adults and Children)

As needed

Same day additional pairs of glasses purchases

As needed

Contact Lens Supply

1 annual supply every 12 months

Promotional Sunglasses with purchase of annual supply of contact lenses

1 pair per annual supply of contact lenses

Discounts for prescription drugs and over the counter drugs

Excluded

Vision Therapy Evaluations

Excluded

Vision Therapy Sessions

Excluded

Vision Therapy Equipment

Excluded

Medical eye care, including, but not limited to, myopia control, corneal refractive therapy, orthokeratology, medical or surgical treatment of the eyes, red eyes, pink eyes, allergies, glaucoma, dry eye, macular degeneration, cataracts, any other eye diseases, amblyopia (lazy eye), strabismus, non-strabismic binocular vision disorders, visual perceptual disorders, traumatic brain injury, headaches, diplopia (double vision)

Excluded

Services performed by a non-participating eye care or medical provider

Excluded

Any services or materials in progress that has begun prior to enrollment must be completed by the optometrist who began the work (whether or not a Network Optometrist)

 

Excluded

Medical care not otherwise listed

Excluded

 

13.  Your Responsibility for Payment and Fees: Once you or any of your dependents receive services or materials from a Network Optometrist, you will be billed directly by your Network Optometrist for services rendered and materials ordered. You will be responsible for paying the billed amount directly to your Network Optometrist at the time of service. THIS IS A SAVINGS PLAN ONLY. No payments will be made by MHSP either to you or your Network Optometrist.

 

Disputes: As required by Ohio Law, MHSP provides a grievance system to resolve any dispute or grievance you may have with your Network Optometrist or with MHSP itself. You have thirty (30) days after any incident or action to submit a grievance. MHSP will acknowledge the receipt of your grievance within ten (10) business days after MHSP receives it and will send you notification of the resolution of your grievance within thirty (30) days after receipt. If you are not satisfied by MHSP’s resolution of your grievance, you may seek review with the Ohio Department of Insurance at 800-686-1526 or contact the Department via mail at


Ohio Department of Insurance
50 W. Town Street
Third Floor – Suite 300
Columbus, Ohio 43215.

 

You may submit a written grievance to:

 

Modern Heritage Eye Care, LLC

Members Only Optometric Savings Plan

5150 Chappel Dr.

Perrysburg, OH 43551

 

14.  Termination of Network Optometrist: If your Network Optometrist ceases to be in network and MHSP has a record of who your Network Optometrist is, MHSP will promptly notify you so that you can make arrangements to see another Network Optometrist. MHSP will also post a notice on its website of all Network Optometrists who are no longer in network. This includes a Network Optometrist who has given notice of termination, been terminated, or who otherwise is no longer able to provide services. The effective date of termination will also be listed. You may also contact MHSP for information on whether or not your optometrist is still a Network Optometrist.

 

Every Network Optometrist’s contract with MHSP stipulates that upon termination of the contract, the Network Optometrist must complete all procedures begun before termination at the cost savings rates outlined in Section 18. If MHSP should ever cease operations, your Network Optometrist will continue to render services at the cost savings rate to you and your dependents until the current annual membership year has ended.

 

15.  If you have Vision Insurance: Since MHSP is not insurance and does not provide insurance, it will not coordinate benefits with any vision or medical insurance you or your dependents may have. If you have vision or medical insurance, you should contact your vision or medical insurer for information on what benefits will or will not be paid.

 

16.  HIPAA and Patient Confidentiality: Each Network Optometrist and MHSP itself is required by law to keep your personal healthcare information confidential. Information cannot and will not be released without your written consent or as expressly authorized by law. Please refer to the Modern Heritage Eye Care Privacy Policy for full details.

 

17.  Summary of Savings: The following is a summary of the major categories of optometric services and materials available under this Plan and the average savings for each category of services. The average savings is the difference between what your Network Optometrist charges and what is considered usual, customary, and reasonable.

18.  THIS IS ONLY A SUMMARY. PLEASE CONSULT THE FEE SCHEDULE TO DETERMINE THE EXACT FEE FOR ANY PARTICULAR OPTOMETRIC SERVICE.

 

Category

Average Plan Savings

Comprehensive Annual Eye Examination

50%

Refraction

50%

Contact lens fees (annual re-evaluation, fittings, and classes)

25%

Adult Prescription Eyewear Packages (1st pair)

30%

Adult Prescription Eyewear Packages (additional pairs purchased on the same day as 1st pair)

50%

Pediatric Prescription Eyewear Packages

10%

Pediatric Prescription Eyewear Packages (additional pairs purchased on the same day as 1st pair)

20%

Non-prescription sunglasses with purchase of annual supply of daily disposable contact lenses (1 per 12 months)

100%

Non-prescription sunglasses with purchase of annual supply of contact lenses other than daily disposable contact lenses (1 per 12 months)

$40.00

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