Download Small Business Program 2016

Small Business Program 2016
We keep you smiling ®
Delta Dental Insurance Company
Delta Dental of Delaware, Inc.
Delta Dental of New York, Inc.
Delta Dental of Pennsylvania
Delta Dental of West Virginia
Alpha Dental Programs, Inc.
Businesses of all sizes are big on value.
That’s why Delta Dental created a portfolio of its most popular plans — each
specially designed to provide maximum value for your small business.
You can rely on Delta Dental to provide cost management, superior access to
dentists and dental plans to meet your needs.
No matter which Delta Dental plan you choose, you can feel confident
knowing that you’ve chosen a plan that protects your employees and offers
your business big value.
Delta Dental PPOSM
Delta Dental PPO is our open network plan that balances moderate savings with
maximum access to network dentists. Enrollees may visit any licensed dentist
but usually have the lowest out-of-pocket costs when visiting a PPO dentist. Delta
Dental offers access to one of the largest contracted networks of its kind in the
U.S., with two levels of savings; Delta Dental PPO and Delta Dental Premier®.
Through this two-tier network approach, enrollees are protected from the higher
costs that are likely when services are provided by non-Delta Dental dentists. Our
small business program offers employers access to a variety of plan options often
available only to large employers. These options include PPO plan designs that
reimburse the dentist based on the PPO provider’s contracted fee both in- and
out-of-network or the PPO plus Premier plan designs that will reimburse Delta
Dental Premier dentists based on their contracted Premier fee.
With PPO plus Premier — our unique PPO plan design feature — employers
can take advantage of the savings from the PPO plan while providing employees
with expanded access to Delta Dental dentists who can limit their out-of-pocket
costs. PPO dentists accept fees that are more deeply discounted than the fees
accepted by dentists who participate in the larger Premier network. Employees
who visit a non-PPO dentist can save more by visiting a Premier dentist than
they can by visiting a non-Delta Dental dentist. PPO plus Premier provides
maximum network access while offering deeper savings within the PPO
network and a level of cost protection with the Premier network.
All Delta Dental dentists make visits easy and convenient because they file
claims and accept payment for services directly from Delta Dental. Patients
are only responsible for their share at the time of treatment —they pay no
more than the fees allowed by Delta Dental, thus are not required to pay
the entire claim up front and wait for reimbursement when they visit a
Delta Dental dentist.
DeltaCare® USA
DeltaCare USA is our closed network prepaid plan that features set copayments,
no annual deductibles and no maximums for covered benefits. Enrollees
must select a primary care dentist in the DeltaCare USA network from whom
they receive treatment, as in a traditional dental HMO. With DeltaCare USA,
businesses enjoy higher cost controls, while still providing employees with a
broad range of dental benefits.
DeltaCare USA delivers quality care for less cost than our traditional fee-forservice plans. DeltaCare USA dentists undergo a comprehensive credentialing
process to ensure they meet high-quality standards. The majority of diagnostic
and preventive procedures are covered at no cost to the enrollee.
DeltaCare USA plans are available in District of Columbia, Maryland, New York,
Pennsylvania and West Virginia.
Table of Contents
Delta Dental PPO — Employer–Paid
2-3
Delta Dental PPO — Voluntary
4-5
How the PPO Plan Works
6
PPO Underwriting Guidelines
7
PPO Limitations and Exclusions
8
DeltaCare USA
9
Using The DeltaCare USA Plan
10
DeltaCare USA Underwriting Guidelines
11
DeltaCare USA Limitation and Exclusions
12-13
Delta Dental’s Value Proposition
14
Delta Dental’s Mission Statement
15
Delta Dental PPO — Employer Paid
Summary of Benefits1
PPO 1
PPO Dentists/
NonPPO Dentists
Reimbursement Basis
For businesses with 2-99 eligible employees
PPO 2
PPO Dentists/
NonPPO Dentists
PPO 32
PPO Dentists/
NonPPO Dentists
PPO 4
PPO Dentists/
NonPPO Dentists
PPO A
PPO
Dentists
PPO B
NonNonPPO
PPO
PPO
Dentists
Dentists
Dentists
Delta Dental PPO, Delta Dental Premier and Non-Delta Dental dentists: the lesser of the
submitted charge or the PPO provider contracted fee.
Diagnostic (deductible waived)
• Exams (two per calendar year)
• Bitewing x-rays (two per calendar year)
100%
100%
100%
100%
100%
80%
100%
80%
Preventive (deductible waived)
• Prophylaxis (cleaning) (two per calendar
year and one additional cleaning for
pregnant women)
• Fluoride treatments (to age 19) (two per
calendar year)
• Sealants (to age 14)
• Space maintainers (to age 14)
100%
100%
100%
100%
100%
80%
100%
80%
Basic Restorative
•F
illings (amalgam “silver” and composite
“white” non-molar)
50%
80%
80%
80%
80%
60%
80%
60%
Oral Surgery
•E
xtraction and oral surgery procedures
including pre- and post-operative care
•G
eneral anesthesia and IV sedation are covered when used in conjunction with covered
oral surgical procedures
Not a
benefit
80%
80%
80%
80%
60%
80%
60%
Endodontics
• Pulpal therapy
• Root canal therapy
Not a
benefit
80%
80%
80%
80%
60%
80%
60%
Periodontics
•T
reatment to the gums and supporting
structures of the teeth
Not a
benefit
80%
80%
80%
80%
60%
80%
60%
Major Restorative3
• Inlays
• Onlays
• Crowns
Not a
benefit
Not a
benefit
50%
50%
50%
50%
50%
50%
Prosthodontics3
•P
rocedures for replacement of missing
teeth by construction or repair of bridges
and partial or complete dentures
Not a
benefit
Not a
benefit
50%
50%
50%
50%
50%
50%
Implants3
Not a
benefit
Not a
benefit
50%
50%
50%
50%
50%
50%
Orthodontics3
•S
traightening of teeth (children only to
age 19)
• $1,000 lifetime maximum (per person)
Not a
benefit
Not a
benefit
Not a
benefit
50%
50%
50%
Calendar year deductibles (per person/per
family)
$25/$75
$50/$150
$50/$150
$50/$150
$1,000
$1,500
$1,500
$1,500
Calendar year maximum (per person)
Not a
benefit
$50/
$150
$75/
$225
$50/
$150
$75/
$225
$1,500 $1,000 $1,500 $1,000
1
Subject to Limitations and Exclusions shown on page 8. The benefit explanations contained herein are subject to all provisions of the group dental service contract
and do not modify such contract in any way, nor shall the enrollee accrue any rights because of any statement in or omission from this highlight sheet.
2
Groups with 2-4 eligible employees are limited to PPO 3, PPO Plus Premier 3 and PPO V2, and a calendar year maximum of $1,000 will apply ($1,000/$750 for PPO
Plus Premier 3).
3
For groups under 25 employees there is a six-month waiting period for all major restorative, prosthodontic, implant and orthodontic services. The waiting period may be
waived if group can provide proof of prior comprehensive group dental coverage with no break in coverage (copy of group’s prior carrier’s EOC and last bill).
2
Delta Dental PPO — Employer Paid
Summary of Benefits1
PPO plus
Premier 1
PPO Dentists/
NonPPO Dentists
Reimbursement Basis
For businesses with 2-99 eligible employees
PPO plus
Premier 2
PPO Dentists/
NonPPO Dentists
PPO plus
Premier 32
PPO Dentists/
NonPPO Dentists
PPO plus
Premier 4
PPO Dentists/
NonPPO Dentists
PPO plus
Premier A
PPO
Dentists
PPO plus
Premier B
NonNonPPO
PPO
PPO
Dentists
Dentists
Dentists
Delta Dental PPO dentists: the lesser of the submitted charge or the PPO provider contracted
fee.
Delta Dental Premier and Non-Delta Dental dentists: the lesser of the submitted charge or the
Premier provider contracted fee.
Diagnostic (deductible waived)
• Exams (two per calendar year)
• Bitewing x-rays (two per calendar year)
Preventive (deductible waived)
• Prophylaxis (cleaning) (two per calendar
year and one additional cleaning for
pregnant women)
• Fluoride treatments (to age 19) (two per
calendar year)
• Sealants (to age 14)
• Space maintainers (to age 14)
100%
100%
100%
100%
100%
80%
100%
80%
100%
100%
100%
100%
100%
80%
100%
80%
Basic Restorative
•F
illings (amalgam “silver” and composite
“white”non-molar)
Oral Surgery
•E
xtraction and oral surgery procedures
includingpre- and post-operative care
•G
eneral anesthesia and IV sedation are
covered when used in conjunction with
covered oral surgical procedures
50%
80%
80%
80%
80%
60%
80%
60%
Not a
benefit
80%
80%
80%
80%
60%
80%
60%
Endodontics
• Pulpal therapy
• Root canal therapy
Periodontics
•T
reatment to the gums and supporting
structures of the teeth
Not a
benefit
80%
80%
80%
80%
60%
80%
60%
Not a
benefit
80%
80%
80%
80%
60%
80%
60%
Major Restorative3
• Inlays
• Onlays
• Crowns
Not a
benefit
Not a
benefit
50%
50%
50%
50%
50%
50%
Prosthodontics3
•P
rocedures for replacement of missing
teeth by construction or repair of bridges
and partial or complete dentures
Not a
benefit
Not a
benefit
50%
50%
50%
50%
50%
50%
Implants3
Not a
benefit
Not a
benefit
Not a
benefit
Not a
benefit
50%
50%
50%
50%
50%
50%
Not a
benefit
50%
50%
50%
$25/$75
$50/$150
$50/$150
$50/$150
$50/
$150
$75/
$225
$1,500
$2,000
$2,000
$2,000
$1,500
$1,500
$1,000
$1,500
$1,500
$1,500
$1,000
$1,000
Orthodontics3
•S
traightening of teeth (children only to
age 19)
• $1,000 lifetime maximum (per person)
Calendar year deductible (per person/per
family)
Calendar year maximum (per person)
• Services provided by a PPO dentist
• Services provided by a Premier or nonDelta Dental dentist
Not a
benefit
$50/
$150
$75/
$225
See footnotes on page 2.
3
Delta Dental PPO Voluntary
For businesses with 2-99 eligible employees
Summary of Benefits1
PPO V1
Reimbursement Basis
Diagnostic (deductible waived)
PPO V22
PPO
MPB13
PPO
MPB23
Delta Dental PPO, Delta Dental Premier and NonDelta Dental dentists: the lesser of the submitted
charge or the PPO provider contracted fee.
100%
100%
100%
100%
100%
100%
100%
100%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
Not a
benefit
50%
Not a
benefit
50%
Not a
benefit
50%
Not a
benefit
50%
• Exams (two per calendar year)
• Bitewing x-rays (two per calendar year)
Preventive (deductible waived)
• Prophylaxis (cleaning) (two per calendar and one additional cleaning for
pregnant women)
• Fluoride treatments (to age 19) (two per calendar year)
• Sealants (to age 14)
• Space maintainers (to age 14)
Basic Restorative
• Fillings (amalgam “silver” and composite “white” non-molar)
Oral Surgery4
• Extraction and oral surgery procedures including pre- and post-operative care
• General anesthesia and IV sedation are covered when used in conjunction with
covered oral surgical procedures
Endodontics4
• Pulpal therapy
• Root canal therapy
Periodontics4
• Treatment to the gums and supporting structures of the teeth
Major Restorative5
• Inlays
• Onlays
• Crowns
Prosthodontics5
• Procedures for replacement of missing teeth by construction or repair of
bridges and partial or complete dentures
Implants5
Not a
benefit
50%
Not a
benefit
50%
Orthodontics
Not a
benefit
Not a
benefit
Not a
benefit
Not a
benefit
$50/$150
$50/$150
$50/$150
$50/$150
$1,000
$1,000
$1,000
$1,000
Calendar year deductible (per person/per family)
Calendar year maximum (per person)
1
Subject to Limitations and Exclusions on page eight. The benefit explanations contained herein are subject to all provisions of the group dental service
contract, and do not modify such contract in any way, nor shall the enrollee accrue any rights because of any statement in or omission from this
highlight sheet.
2
Groups with 2-4 eligible employees are limited to PPO 3, PPO Plus Premier 3 and PPO V2, and a calendar year maximum of $1,000 will apply ($1,000/$750 for
PPO Plus Premier 3).
3
NY PPO Minimum Participation Base plans.
4
There is a six-month waiting period for all oral surgery, endodontics and periodontics services. The waiting period may be waived if the group can provide proof
of prior comprehensive group dental coverage with no break in coverage (copy of group’s prior carrier’s EOC and last bill).
5
There is a 12-month waiting period for all major restorative, prosthodontic and implant services. The waiting period may be waived if the group can
provide proof of prior comprehensive group dental coverage with no break in coverage (copy of group’s prior carrier’s EOC and last bill).
4
Delta Dental PPO Voluntary
For businesses with 2-99 eligible employees
Summary of Benefits1
Reimbursement Basis
Diagnostic (deductible waived)
PPO plus
Premier
V1
PPO plus
Premier
V2
PPO plus
Premier
MPB13
PPO plus
Premier
MPB23
Delta Dental PPO dentists: the lesser of the submitted
charge or the PPO provider contracted fee.
Delta Dental Premier and Non-Delta Dental dentists:
the lesser of the submitted charge or the Premier
provider contracted fee.
100%
100%
100%
100%
100%
100%
100%
100%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
Not a
benefit
50%
Not a
benefit
50%
Not a
benefit
50%
Not a
benefit
50%
• Exams (two per calendar year)
• Bitewing x-rays (two per calendar year)
Preventive (deductible waived)
• Prophylaxis (cleaning) (two per calendar and one additional cleaning for
pregnant women)
• Fluoride treatments (to age 19) (two per calendar year)
• Sealants (to age 14)
• Space maintainers (to age 14)
Basic Restorative
• Fillings (amalgam “silver” and composite “white” non-molar)
Oral Surgery4
• Extraction and oral surgery procedures including pre- and post-operative care
• General anesthesia and IV sedation are covered when used in conjunction with
covered oral surgical procedures
Endodontics4
• Pulpal therapy
• Root canal therapy
Periodontics4
• Treatment to the gums and supporting structures of the teeth
Major Restorative5
• Inlays
• Onlays
• Crowns
Prosthodontics5
• Procedures for replacement of missing teeth by construction or repair of bridges
and partial or complete dentures
Implants5
Not a
benefit
50%
Not a
benefit
50%
Orthodontics
Not a
benefit
Not a
benefit
Not a
benefit
Not a
benefit
$50/$150
$50/$150
$50/$150
$50/$150
Calendar year maximum (per person)
• Services provided by a PPO dentist
$1,500
$1,500
$1,500
$1,500
• Services provided by a Premier or non-Delta Dental dentist
$1,000
$1,000
$1,000
$1,000
Calendar year deductible (per person/per family)
See footnotes on page 4.
5
How the Delta Dental PPO Plan Works
Delta Dental PPO plans provide access to one of the largest networks of its kind nationwide. Delta Dental PPO dentists agree to accept
reduced fees as payment in full for covered procedures when treating PPO patients. This means enrollee’s out-of-pocket costs are usually lower when they visit a PPO dentist than when they visit a non-Delta Dental dentist.
When covered under the PPO plan, enrollees:
•
•
•
•
•
Can visit any licensed dentist, including a dental specialist of choice
May change dentists at any time without notifying us
Can receive dental care anywhere in the world (Non-PPO benefits apply)
Will not have to pay more than the patient’s share1 for covered services or file claim forms when visiting a Delta Dental dentist.
Delta Dental dentists file claim forms for enrollees and accept payment directly from Delta Dental.
Can visit a Delta Dental Premier dentist. Delta Dental Premier dentists will not bill above their contracted fees, but they may charge
the difference between the PPO contracted fee and the Premier contracted fee.
Delta Dental PPO plus Premier plans combine the PPO and Premier networks to maximize opportunities to save money. If an enrollee
cannot visit a PPO dentist, the best alternative is to choose a dentist from the Delta Dental Premier network because these dentists also
agree to accept limited fees for services and will not bill above the Premier contracted fees.
Locating a Delta Dental PPO dentist
Enrollees may visit our online directory at deltadentalins.com to find a Delta Dental PPO dentist anywhere in the U.S.
For a comparative example of out-of-pocket costs that PPO enrollees might incur when visiting either a Delta Dental PPO, Delta Dental
Premier or non-Delta Dental dentist, please see the hypothetical chart below:
PPO
Delta Dental PPO Dentist
Delta Dental Premier Dentist
Non-Delta Dental Dentist
$180
$180
$180
$90
(PPO provider’s
contracted fee)
$130
(Premier provider’s
contracted fee)
$180
(No fee agreement with
Delta Dental)
Delta Dental’s payment (50%)2
$45
$45
$45
Patient’s share
$45
$85
$135
Delta Dental PPO Dentist
Delta Dental Premier Dentist
Non-Delta Dental Dentist
$180
$180
$180
$90
(PPO provider’s
contracted fee)
$130
(Premier provider’s
contracted fee)
$180
(No fee agreement with
Delta Dental)
Delta Dental’s payment (50%)2
$45
$65
$653
Patient’s share
$45
$65
$115
Dentist bills (submitted charge)
Dentist accepts as payment
in full
PPO plus Premier
Dentist bills (submitted charge)
Dentist accepts as payment
in full
1
The patient’s share for covered services is their coinsurance, remaining deductible, any amount over the annual maximum, and any unpaid difference between
the Premier provider’s contracted fee and the PPO contracted fee.
2 Hypothetical example for illustrative purposes assumes that the plan’s deductible has been previously satisfied, that the annual maximum has not been reached,
and that benefit levels for in- and out-of-network treatment are both at 50%.
3 Non-contracted dentists are paid the lesser of the submitted fee or Premier provider contracted fee.
6
Delta Dental PPO Underwriting Guidelines
Group size
Businesses with 2 to 99 eligible employees. Groups with 5 or more eligible employees must initially enroll and
maintain a minimum of 5 primary enrollees (2 for groups with 2-4 eligible employees) for the duration of the
contract. Groups with 2-4 primary enrollees are limited to plans PPO 3, PPO Plus Premier 3 and PPO V2.
Out-of-state employees
Eligible employees residing out of state are allowed.
Eligible industries
See rate sheets for a complete list of eligible/ineligible industries.
Employer contribution
PPO — Employer Paid
• Employer contributes at least 50% of the cost of the plan (no more than 50% contribution by employee).
PPO — Voluntary and NY Minimum Participation Base
• Employer contributes less than 50% of the cost of the plan (employee may contribute up to 100% towards
the cost of the plan).
Participation
requirement
PPO — Employer Paid
• At least 75% of eligible employees (excluding those with dental coverage elsewhere) must enroll.
• At least 50% of the employees with dependents must enroll their dependents.
• All eligible dependents not covered under another group plan must be enrolled as dependent enrollees if
dependent coverage is elected.
PPO — Voluntary (not available in New York)
• At least 25% of eligible employees (excluding those with dental coverage elsewhere) must enroll.
• All eligible dependents not covered under another group plan must be enrolled as dependent enrollees if
dependent coverage is elected.
PPO — NY Minimum Participation Base (New York only)
• At least 50% of eligible employees or two enrolled employees, whichever is fewer.
• All eligible dependents not covered under another group plan must be enrolled as dependent enrollees if
dependent coverage is elected.
Program waiting period
PPO — Employer Paid
Groups with 2-24 primary enrollees
• Subject to a six month waiting period from group’s effective date for major restorative, prosthodontic,
implants and orthodontics (if covered) benefits. The waiting period may be waived if the group can provide
proof of prior comprehensive group dental coverage with no break in coverage (copy of group’s prior
carrier’s EOC and last bill).
Groups with 25-99 primary enrollees
• No waiting period.
PPO — Voluntary and NY Minimum Participation Base (New York only) Plans
• Subject to a six month waiting period for oral surgery, endodontic and periodontic services. The waiting
period may be waived if the group can provide proof of prior comprehensive group dental coverage with no
break in coverage (copy of group’s prior carrier’s EOC and last bill).
• Subject to a 12-month waiting period for major restorative, prosthodontic and implants services. The waiting
period may be waived if the group can provide proof of prior comprehensive group dental coverage with no
break in coverage (copy of group’s prior carrier’s EOC and last bill).
Eligible employees
• Full-time, permanent employees will be entitled to receive benefits after completing all eligibility
requirements of the employer.
• Contract employees (category 1099 employees) are not eligible.
• A group of two cannot be comprised of a dependent relationship, e.g. husband and wife.
Eligible dependents
• Legal spouse or domestic partner (if offered by group).
• Dependent children to age 26 for all covered services, except orthodontic services.
• Orthodontic treatment, if applicable, covers dependent children to age 19.
New employee/
dependent enrollment
• New employees must enroll within 30 days of satisfying their eligibility requirements.
• Dependents must enroll within 30 days of becoming eligible.
Employee or dependent
terminations
• Dental coverage will end on the last day of the month when an employee is no longer eligible for coverage.
• Dependent coverage will end at the same time as the employee or when the dependent is no longer eligible.
Waive coverage
PPO — Employer–Paid
• Employees or dependents can waive coverage if they have coverage elsewhere (i.e., spouse’s plan).
• Participation in other coverage will count toward Delta Dental’s participation requirement.
PPO — Voluntary and NY Minimum Participation Base (New York only) Plans
• Employees or dependents can waive coverage.
Dual choice
• Employer can offer a PPO plan with a DeltaCare USA plan.
• 10 or more eligible and enrolled employees – minimum of 5 in each plan.
• Less than 10 eligible and/or enrolled employees – minimum of 2 in each plan (5 enrolled in
DeltaCare USA in NY). When enrolling less than 5 in PPO, use the 2-4 rates.
Open enrollment
Employees may enroll, terminate or change coverage based on the group’s open enrollment policy.
Changing Benefits
Groups must wait until anniversary to change benefits.
7
Delta Dental PPO Plan
Limitations and Exclusions
Limitations
THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.
The group dental service contract must be consulted to
determine the exact terms and conditions of coverage.
Benefits, limitations and exclusions may vary by state.
4. Treatments or supplies primarily for cosmetic purposes,
except as part of a treatment dentally necessary due to
accident or injury and directly attributable thereto and except
for reconstructive surgery necessary because of a congenital
disease or anomaly of a covered dependent child which has
resulted in a functional defect.
5. Services provided or supplies furnished or devices started
prior to the effective eligibility date of a patient, unless the
treatment was a year in duration and was completed after the
enrollee became eligible.
1. Prophylaxis and exams are a benefit twice in a calendar
year.
2. Bitewing x-rays are a benefit twice in a calendar year.
3. Complete intraoral series and panoramic films are each
limited to once every three years.
4. Sealants are a benefit, limited to age 14 on unfilled
permanent first and second molars. Treatment with
sealants as a covered service is limited to applications to
eight posterior teeth. Applications to deciduous teeth or
teeth with caries are not covered services. Sealants will
be replaced only after three years have elapsed following
any prior provision of such materials.
6. Preventive plaque control programs, including oral hygiene
programs.
7. Periodontal splinting, equilibration and gnathological
recordings.
8. Myofunctional therapy, unless covered by the exception in
exclusion two above.
Pregnant enrollees may receive an additional benefit
per calendar year: one additional routine prophylaxis
or one additional periodontal scaling and root planning
per quadrant. Written confirmation of the pregnancy
must be provided by the enrollee or her dentist when
the claim is submitted.
9. Temporomandibular joint dysfunction unless covered under
the group contract.
5. 6. Flouride applications are a benefit twice in a calendar
year up to age 19.
7. Space maintainers are a benefit up to age 14.
8.
Episodes of surgical periodontal treatment must be
separated by a period of no less than three years to
qualify the patient for additional periodontal benefits.
9. Substandard work until corrected.
10. Payment of any claim, bill or other demand or request
for payment for health care services that the appropriate
regulatory board determines were provided as a result
of a prohibited referral. (Maryland only)
Exclusions
1.
2. 3. 8
Treatment for materials provided in a hospital or any
other surgical treatment facility unless covered under
the group contract.
Procedures to correct skeletal malformations, except
for treatment due to accidental injury to sound natural
teeth within 12 months of the accident or treatment
necessary due to congenital disease or anomaly, or
treatment of enamel hypoplasia (lack of development),
except that this exclusion shall not apply to covered
dependent children or eligible newborn children.
Treatments or devices that increase the vertical dimension
of an occlusion, restore an occlusion to normal, replace
tooth structure lost by attrition or erosion, or otherwise,
except as part of a treatment dentally necessary due to
accident or injury and directly attributable thereto.
10. Implants are not a benefit under PPO 1, PPO 2, PPO plus
Premier 1, PPO plus Premier 2, PPO V1, PPO MPB1, PPO
plus Premier V1 and PPO plus Premier MPB1.
11. Prescription drugs, pre-medication, and relative analgesias.
12. Treatment or supplies for which the patient would have no
legal obligation to pay in the absence of this or any other
similar coverage.
13. Experimental procedures.
14. Anesthesia, except for general anesthesia and IV sedation
given by a dentist for covered oral surgery procedures and
select endodontic and periodontic procedures.
15. Major restorative services, inlays, onlays and crowns are not a
benefit under PPO 1, PPO 2, PPO plus Premier 1, PPO plus
Premier 2, PPO V1, PPO MPB1, PPO plus Premier V1 and
PPO Plus Premier MPB1.
16. Prosthodontic services, including bridges and dentures, are
not a benefit under PPO 1, PPO 2, PPO plus Premier 1, PPO
plus Premier 2, PPO V1, PPO MPB1, PPO plus Premier V1
and PPO plus Premier MPB1.
17. Orthodontic services, including tooth guide appliances, are
not a benefit under PPO 1, PPO 2, PPO 3, PPO plus Premier
1, PPO plus Premier 2, PPO plus Premier 3, PPO V1, PPO
MPB1 PPO V2, PPO MPB2, PPO plus Premier V1, PPO plus
Premier MPB1, PPO plus Premier V2 and PPO plus Premier
MPB2.
18. Endodontics, periodontics and oral surgery are not a benefit
under PPO 1 and PPO plus Premier 1.
19. Adult orthodontics.
DeltaCare USA1
Sample Procedures3
For businesses with 22 - 99 eligible employees with
and without Employer Contribution
Sample Patient Copayments
PLAN 13A
PLAN 15A
PLAN M73
(Not available in
New York)
Prophylaxis cleaning — adult (one per six month period)
D1110
No cost
$5
No cost
Bitewing — single radiographic image
D0270
No cost
No cost
No cost
Bitewings — four radiographic images — limited to 1 series every
6 months
D0274
No cost
No cost
$20
Topical application of fluoride — excluding varnish — child
— to age 19; one per six month period
D1208
No cost
No cost
No cost
Amalgam two surfaces, primary or permanent
D2150
No cost
$12
$48
Extraction, coronal remnants — deciduous tooth
D7111
No cost
$10
$45
Sealant, per tooth — limited to permanent molars through age 15
D1351
$10
$15
$15
Periodontal scaling and root planing — one to three teeth per
quadrant
D4342
$40
$50
$60
Crown — full cast noble metal
D2792
$295
$335
$465
Root canal — endodontic therapy, molar (excluding final restoration)
$335
$365
$470
$285
$365
$600
Comprehensive orthodontic treatment of the transitional
dentition — child or adolescent to age 19
D8070
$1,900
$1,900
75 percent of the
contract orthodontist’s
“filed fee”
Comprehensive orthodontic treatment of the adult dentition —
adults, including covered dependent adult children
D8090
$2,100
$2,100
75 percent of the
contract orthodontist’s
“filed fee”
D3330
Complete denture — maxillary
D5110
1
2
3
DeltaCare USA is not available in Delaware.
In New York, groups must initially enroll and maintain a minimum of 5 primary enrollees for the duration of the contract.
2016 Current Dental Terminology codes under copyright by the American Dental Association (ADA). Subject to Limitations and Exclusions beginning
on page 12. A complete listing of procedures and copayments, as well as benefit frequency limitations, may be found in the Description of Benefits and
Copayments (available upon request).
Benefits
The following are included in all three DeltaCare USA plans:
•
•
•
•
•
•
No claim forms
No deductibles
No annual maximums
Access to specialty care
Professional treatment standards
Out-of-pocket costs are clearly defined
DeltaCare USA enrollees must select a contract dental office in the state where the group is headquartered to provide care for
themselves and their families. The low turnover rate among DeltaCare USA dentists means enrollees can enjoy a long-term
relationship with their family dentist.
9
Using The DeltaCare USA Plan
DeltaCare USA promotes great dental health for enrollees and their families with quality dental benefits at an affordable cost. By covering many services at no cost to the enrollee, Delta Dental encourages regular preventive dental visits. Enrollees must select a contracted
DeltaCare USA dentist to provide covered services.
DeltaCare USA enrollees also enjoy great features including out-of-area emergency coverage, an orthodontic treatment in progress provision and expanded business hours for toll-free customer service (subject to Limitations and Exclusions).
When covered by a DeltaCare USA plan, enrollees:
•
•
•
•
•
•
Won’t be subject to annual deductibles or maximums;
Will know in advance what out-of-pocket costs will be;
Won’t be subject to restrictions on pre-existing conditions, except for work in progress;
Won’t have to complete claim forms and submit them for reimbursement;
Will be covered for accidental injury based on procedures listed in the Description of Benefits and Copayments; and
Will receive a plan in which all listed procedures are covered with set fixed copayments.
Know the name and location of a DeltaCare USA dentist
Enrollees must select and obtain treatment from a primary care dentist listed on DeltaCare USA’s participating dental offices in the state
where the group is headquartered. If enrollees change their DeltaCare USA dentist by the 21st of the month, the change will be effective
on the first day of the following month. If the dentist’s network status changes, Delta Dental will notify the enrollee, but they should
verify their dentist’s status with us by calling Customer Service or by visiting our web site — deltadentalins.com.
How the plan works
Following enrollment in DeltaCare USA, enrollees will receive an ID card and a plan booklet. The booklet contains a complete list
of the procedures and copayments that are covered for the DeltaCare USA plan, as well as plan limitations and exclusions. Delta Dental
will also include in the packet the name, address and phone number of the enrollees’ DeltaCare USA dentist. Enrollees simply call
the dental office to make an appointment. We will notify the DeltaCare USA dentist about the enrollees’ enrollment in the plan,
as well as other important details about enrollee coverage such as dependent information, group number and enrollee ID number.
One of the great features of the plan is that enrollees have a list of the copayments and covered services so they can always refer to it
before visiting the dentist.
Orthodontic treatment in progress
DeltaCare USA has an orthodontic treatment in progress provision that allows new enrollees to continue treatment with their current
orthodontist, so long as the enrollee is in active treatment started under his or her previous employer-sponsored dental plan. Enrollees
are responsible for all copayments and fees subject to the provisions of their prior dental plan.
10
DeltaCare USA Underwriting Guidelines
Group size
Businesses with 2 to 99 eligible employees (5 to 99 in New York). Group must initially enroll and maintain a
minimum of 2 primary enrollees (5 in New York) for the duration of the contract.
Eligible industries
See rate page for a list of eligible/ineligible industries.
Employer contribution
Employer will provide payroll deduction for employee contributions.
With employer contribution
• Employer contributes at least 25% of the cost of the plan.
Without employer contribution — Voluntary
• Employer may contribute up to 24.9% of the cost of the plan.
Participation requirement
Employee
• A minimum of 2 primary enrollees (5 in New York) must enroll.
Dependent
• Dependents are not required to enroll.
• All eligible dependents not covered under another group plan must be enrolled as dependent
enrollees if dependent coverage is elected.
Eligibility waiting period
As required by employer.
Program waiting period
No waiting period for any services.
Eligible employees
• Full-time, permanent employees will be entitled to receive benefits after completing all eligibility
requirements of the employer.
• Contract employees (category 1099 employees) are not eligible.
• A group of two cannot be comprised of a dependent relationship; e.g., husband and wife.
New employee/
dependent enrollment
• New employees must enroll within 30 days of satisfying their eligibility requirements.
• Dependents must enroll within 30 days of becoming eligible.
Eligible dependents
• Legal spouse or domestic partner (if offered by group).
• Dependent children to age 26.
Employee or dependent
terminations
• Dental coverage will end on the last day of the month when an employee is no longer eligible for coverage.
• Dependent coverage will end at the same time as the employee’s or when the dependent is no
longer eligible.
Waive coverage
Employees or dependents can waive coverage.
Orthodontics
Immediately available to new groups without proof of prior orthodontic coverage.
Dual choice
• Employer can offer a PPO plan with a DeltaCare USA plan.
• 10 or more eligible and enrolled employees – minimum of 5 in each plan.
• Less than 10 eligible and/or enrolled employees – minimum of 2 in each plan (5 enrolled
in DeltaCare USA in NY). When enrolling less than 5 in PPO, use the 2-4 rates.
DeltaCare USA dentist
• Enrollees must select and obtain treatment from a primary care dentist listed on DeltaCare USA’s
participating dental offices in the state where the group is headquartered.
Open enrollment
Employees may enroll, terminate or change coverage based on the group’s open enrollment policy.
Out-of-state employees
Out-of-state employees are covered by the plan. However, services must be rendered in the state where
the contract is issued, except New York and Pennsylvania contracts where services must be rendered in
New York, Pennsylvania or New Jersey.
Changing Benefits
Groups must wait until anniversary to change benefits
11
DeltaCare USA Limitations of Benefits
Limitations
THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.
The group dental service contract must be consulted to
determine the exact terms and conditions of coverage.
Benefits, limitations and exclusions may vary by state.
1.
The frequency of certain benefits is limited. All frequency
limitations are listed in Description of Benefits and
Copayments, available upon request:
2.
If the enrollee accepts a treatment plan from the general
dentist that includes any combination of more than
six crowns, bridge pontics and/or bridge retainers, the
enrollee may be charged an additional ($100.00 for plans
13A and 15A) or ($75.00 for plan M73) above the listed
copayment for each of these services after the sixth unit
has been provided;
3.
General anesthesia and/or intravenous sedation/
analgesia is limited to treatment by a contracted oral
surgeon and in conjunction with an approved referral
for the removal of one or more partial or full bony
impactions, (Procedures D7230, D7240, and D7241);
4.
For plans 13A and 15A, benefits provided by a pediatric
dentist are limited to children through age seven
following an attempt by the assigned contract dentist
to treat the child and upon prior authorization by the
plan less applicable copayments. Exceptions for medical
conditions, regardless of age limitation will be considered
on an individual basis.
For plan M73, benefits provided by a contract pediatric
dentist are available at 75 percent of the contract
specialist’s “filed fees.” Referral by the assigned contract
dentist is required before services are rendered;
5.
The cost to an enrollee receiving orthodontic treatment
whose coverage is cancelled or terminated for any reason
will be based on the contract orthodontist’s usual fee for
the treatment plan. The contract orthodontist will prorate
the amount for the number of months remaining to
complete treatment. The enrollee makes payment directly
to the contract orthodontist as arranged;
Maryland Only:
Should an enrollee’s coverage be cancelled or terminated
for any reason, and at the time of cancellation or
termination the enrollee is receiving orthodontic
treatment, the enrollee will be solely responsible for
payment for treatment provided after cancellation or
termination, except:
If an enrollee is receiving ongoing orthodontic treatment
12
at the time of termination, ALPHA will continue to
provide orthodontic benefits for:
— 60 days if the enrollee is making monthly payments to
the contract orthodontist, or
— until the later of 60 days or the end of the quarter in
progress, if the enrollee is making quarterly payments
to the contract orthodontist.
At the end of 60 days (or at the end of the quarter),
the enrollee’s obligation will be based on the contract
orthodontist’s usual fee for the treatment plan. The
contract orthodontist will prorate the amount over the
number of months remaining in the initial 24 months of
treatment. The enrollee will make payments based on an
arrangement with the contract orthodontist.
6.
Orthodontic treatment in progress is limited to new
DeltaCare USA enrollees who, at the time of their original
effective date, are in active treatment started under their
previous employer sponsored dental plan as long as they
continue to be eligible under the DeltaCare USA program.
Active treatment means tooth movement has begun.
Enrollees are responsible for all copayments and fees
subject to the provisions of their prior dental plan. The
plan is financially responsible only for amounts unpaid by
the prior dental plan for qualifying orthodontic cases.
7.
Pennsylvania Only:
A pre-existing condition is a disease or physical condition
caused by illness or injury for which medical advice or
treatment has been received within 90 days immediately
prior to becoming eligible with the DeltaCare USA
program. A pre-existing condition shall be covered after
an enrollee has been covered for more than 12 months
under the group contract. Example: teeth prepared for
crowns, root canals in progress, orthodontic treatment.
If an enrollee begins comprehensive orthodontic
treatment within 90 days immediately prior to
becoming eligible under the DeltaCare USA
program, a provision for treatment in progress is
available, subject to a waiting period of 12 months
of continuous coverage under the DeltaCare USA
program unless the individual qualifies for the onetime orthodontic treatment in progress provision.
DeltaCare USA Exclusions of Benefits
Exclusions
1.
Any procedure that is not specifically listed under
Description of Benefits and Copayments , available upon
request:
2.
Any procedure that in the professional opinion of the
contract dentist:
a.has poor prognosis for a successful result and
reasonable longevity based on the condition of the
tooth or teeth and/or surrounding structures, or
b.is inconsistent with generally accepted standards for
dentistry;
3.
Services solely for cosmetic purposes, with the exception
of procedure D9972, external bleaching, per arch,
or for conditions that are a result of hereditary or
developmental defects, such as cleft palate, upper and
lower jaw malformations, congenitally missing teeth and
teeth that are discolored or lacking enamel, except for the
treatment of newborn children with congenital defects or
birth abnormalities;
4.
Porcelain crowns, porcelain fused to metal, cast metal or
resin with metal type crowns and fixed partial dentures
(bridges) for children under 16 years of age;
5.
Lost or stolen appliances including, but not limited to,
full or partial dentures, space maintainers and crowns
and fixed partial dentures (bridges);
6.
Procedures, appliances or restoration if the purpose is
to change vertical dimension, or to diagnose or treat
abnormal conditions of the temporomandibular joint
(TMJ);
7.
Precious metal for removable appliances, metallic or
permanent soft bases for complete dentures, porcelain
denture teeth, precision abutments for removable
partials or fixed partial dentures (overlays, implants, and
appliances associated therewith) and personalization and
characterization of complete and partial dentures;
8.
Implant-supported dental appliances and attachments,
implant placement, maintenance, removal and all other
services associated with a dental implant;
9.
Consultations for non-covered benefits;
11. Under plan M73 dental services received from any dental
facility other than the assigned contracting dentist,
including the services of an out-of-network dentist
who provides specialized services are excluded unless
expressly authorized by the Administrator, or as covered
under Emergency Services as described in the Contract
and/or Evidence of Coverage (EOC).
12. All related fees for admission, use, or stays in a hospital,
out-patient surgery center, extended care facility, or other
similar care facility;
13. Prescription drugs;
14. Dental expenses incurred in connection with any dental
or orthodontic procedure started before the enrollee’s
eligibility with the DeltaCare USA program. Examples
include: teeth prepared for crowns, root canals in
progress, full or partial dentures for which an impression
has been taken and orthodontics unless qualified for the
orthodontic treatment in progress provision;1
15. Lost, stolen or broken orthodontic appliances;
16. Changes in orthodontic treatment necessitated by
accident of any kind;
17. Myofunctional and parafunctional appliances and/or
therapies;
18. Composite or ceramic brackets, lingual adaptation of
orthodontic bands and other specialized or cosmetic
alternatives to standard fixed and removable orthodontic
appliances;
19. Treatment or appliances that are provided by a dentist
whose practice specializes in prosthodontic services.2
1
Does not apply in Pennsylvania.
2Does not apply in Maryland.
10. Under plans 13A and 15A, dental services received
from any dental facility other than the assigned
contracting dentist, a preauthorized dental specialist,
or a contract orthodontist are excluded, except for
Emergency Services as described in the Contract and/
or Evidence of Coverage (EOC).
13
Value Proposition
We keep you smiling®
Why do 68 million enrollees trust their smiles to Delta Dental?1
Most of our enrollees stay with us year after year2, and it’s no wonder. Delta Dental sets
the industry standard by doing whatever it takes and then some. We deliver:
•Less out-of-pocket. The Delta Dental Difference® saves clients and enrollees
billions of dollars a year.3 Because Delta Dental dentists agree to our
determination of fees, clients enjoy extensive cost controls, and enrollees
pay less out-of-pocket.
•More dentists. Four out of five dentists4 nationwide are contracted Delta
Dental dentists, giving enrollees convenient access and quality assurance
through one of the nation’s largest dentist networks.
•Simpler process. Our dental plans are easy to use. No ID card is required to
receive services and there are no claim forms to file — Delta Dental dentists
do that for you. And because we pay Delta Dental dentists directly, you are
responsible only for your share of payment.
1Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania, Delta Dental Insurance
Company and our affiliated companies form one of the nation’s largest dental benefits delivery systems, covering
33 million enrollees. All of our companies are members, or affiliates of members, of the Delta Dental Plans
Association, a network of 39 Delta Dental companies that together provide dental coverage to almost 68 million
people in the U.S.
2Delta Dental retained 95.7 percent of our 33 million enrollees in 2014.
3Savings due to reduction of premiums or claims liability and patient out-of-pocket costs, based on Delta Dental’s cost
management report, 2014.
4Proportion of total practicing dentists contracted with Delta Dental based on the Delta Dental Plans Association
National Provider File, 2015.
14
Delta Dental’s Mission Statement
To advance dental health and access through
exceptional dental benefits service, technology
and professional support.
15
Call your broker, participating general agent or Delta Dental
Delta Dental’s toll-free number
800-471-7091
Or write to Delta Dental at:
One Delta Drive
Mechanicsburg, PA 17055
[email protected]
Delta Dental PPOSM
Delta Dental Premier® and Delta Dental PPO® is underwritten by Delta Dental Insurance Company in DC, and by
not-for-profit dental service companies in these states: PA and MD — Delta Dental of Pennsylvania; NY — Delta
Dental of New York, Inc.;
DE — Delta Dental of Delaware, Inc.; WV — Delta Dental of West Virginia.
DeltaCare® USA
DeltaCare USA is underwritten in these states by these entities: DC and WV — Delta Dental Insurance Company;
MD — Alpha Dental Programs, Inc.; NY — Delta Dental of New York, Inc.; PA — Delta Dental of Pennsylvania;
Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies
are financially responsible for their own products.
Visit Delta Dental’s website at:
deltadentalins.com
© Delta Dental
SBA DDP #89479 (rev. 8/15)