Download DeltaPreferred Option - Delta Dental Insurance

To d a y ’s b u s i n e s s e s n e e d t o b e
flexible
reliable
and
customer-driven
T h a t ’s w h a t y o u c a n e x p e c t f r o m t h i s d e n t a l p l a n .
D e l t a D e n t a l p ro g ra m s f o r b u s i n e s s e s w i t h 1 0 0 t o 3 9 9 e m p l o y e e s.
Your needs are simple.
You want a quality dental program
that has value written all over it.
Excellent accesss to dentists.
Strong customer support.
And program designs that are
flexible—after all, every
business is unique.
Simple, right?
Managed Fee-for-Service Program
It’s a Snap!® with Delta Dental.
Delta’s managed fee-for-service program.
Snap! is a portfolio of Delta’s
most popular Dental programs,
each providing maximum
value for businesses with
Preferred Provider Program
Delta’s PPO program.
100 to 399 employees.
Delta’s HMO program administered by
Delta affiliate PMI Dental Health Plan.
flexible
reliable
and
customer-driven
But what you’ll really appreciate about Snap! is it’s flexibility.
You can quickly and easily customize a Snap! program to fit your needs by going on the web
at www.deltadentalca.org.
Inside you’ll find program designs and rates for our most popular programs. Choose from these
programs, or receive a fast quote on a program you’ve customized using our available options.
It’s that simple.
Preferred Provider Program
For Businesses with 100-399 Employees
DeltaPreferred Option (DPO) is Delta Dental’s PPO program. Under a DPO program:
• Enrollees can choose any dentist. However, enrollees receive their maximum benefits when visiting a DPO dentist
• DPO Dentists are Delta dentists who have agreed to charge DPO patients reduced fees
• Enrollees have access to more than 10,600 DPO dental offices in California (approximately 44% of the dental offices
in California), making Delta’s DPO network one of the most accessible PPO networks in California. There are
nearly 65,000 DPO dental offices nationwide.
Services (or Benefits)*
Payment Basis
Diagnostic and preventive
services
such as oral exams, x-rays,
cleanings and fluoride treatments
Other basic services
includes fillings, oral surgery,
root canals, periodontal
treatments and sealants
Crowns, cast restorations and
prosthodontics
includes caps, veneers,
dentures** and bridges
Waiting Period
for crowns, cast restorations
and prosthodontics
(Waived for initial enrollees)
Deductible, per calendar year,
(Deductible roll-over credit
available) deductible applies
to both in- and out-of-network
benefits
Deductible exempt on
diagnostic & preventive
services?
Calendar year maximum per person
DPO 1
DPO 2
DPO 3
Benefits
INNETWORK
Benefits
OUT-OFNETWORK
Benefits
INNETWORK
Benefits
at OUT-OFNETWORK
Benefits
INNETWORK
Benefits
OUT-OFNETWORK
DPO preapproved fees
Plan
Allowance***
DPO preapproved fees
Plan
Allowance***
DPO preapproved fees
Plan
Allowance***
100%
100%
100%
100%
100%
80%
90%
80%
80%
80%
80%
80%
60%
50%
50%
50%
50%
50%
12 months
12 months
12 months
$50 per patient
$150 per family
$50 per patient
$150 per family
$50 per patient
$150 per family
Yes
$1,000
Yes
No
$1,000
Yes
No
$1,000
Note: Enrollees outside California will receive the out-of-network benefits.
DPO enrollees enjoy several advantages:
• Enrollees enjoy lower shared costs because DPO dentists usually charge DPO enrollees lower fees compared
to non-DPO dentists
• Enrollees enjoy all the benefits of the Delta Difference®:
no need to fill out claim forms
no paperwork for referrals
no need to wait for reimbursement (dentists receive payment directly from Delta)
professional treatment standards
DPO dentists are also Delta dentists
• Enrollees can easily access DPO dentist network listings:
Search our online directory via our web site at www.deltadentalca.org
Call toll-free (800) 4-AREA-DR (800-427-3237) to obtain a list of participating DPO dentists
Reference the DPO directory available through their employer
*Please refer to the DeltaPreferred Option Limitations and Exclusions section for those services which may not be covered.
**Subject to a maximum allowance (please refer to limitation J in the DeltaPremier and DPO limitations and exclusions section).
***Plan Allowance for Delta dentists is their pre-approved filed fees. For non-Delta dentists, Delta bases its payment on the fees that
satisfy the majority of Delta dentists or the submitted fees whichever are less.
D e l t a P re m i e r a n d D P O L i m i t a t i o n s a n d E x c l u s i o n s
Limitations
a) Initial examinations, periodic examinations and emergency
examinations are Benefits only when the Dentist is a Delta Dentist
with an accepted fee on file with Delta.
b) Only the first two oral examinations, including office visits for
observation and specialist consultations, or combination thereof,
provided to a patient in a calendar year while he or she is an
Enrollee under any Delta program are Benefits under this program.
c) Delta pays for full-mouth x-rays only after five years have elapsed
since any prior set of full-mouth x-rays was provided under any Delta
program.
d) Bitewing x-rays are provided on request by the Dentist, but not
more than twice in any calendar year for children to age 18, or once
in any calendar year for adults ages 18 and over, while the patient is
an Enrollee under any Delta program.
e) Only the first two cleanings, fluoride treatments, or Single
Procedures which include cleaning, or combination thereof, provided to
a patient in a calendar year while he or she is an Enrollee under any
Delta program are Benefits under this program.
f) Sealant Benefits include the application of sealants only to
permanent first molars up to age nine and second molars up to age 14
if they are without caries (decay), or restorations on the occlusal
surface. Sealant Benefits do not include the repair or replacement of a
sealant on any tooth within three years of its application.
g) Direct composite (resin) restorations are Benefits on anterior
teeth and the facial surface of bicuspids. Any other posterior direct
composite (resin) restorations are optional services and Delta’s
payment is limited to the cost of the equivalent amalgam restorations.
h) Crowns, Jackets, Inlays, Onlays, or Cast Restorations are Benefits
on the same tooth only once every five years while the patient is an
Enrollee under any Delta program, unless Delta determines that
replacement is required because the restoration is unsatisfactory as
a result of poor quality of care, or because the tooth involved has
experienced extensive loss or changes to tooth structure or supporting
tissues since the replacement of the restoration.
i) Prosthodontic appliances that were provided under any Delta
program, including but not limited to fixed bridges and partial or
complete dentures, will be replaced only after five years have passed,
unless Delta determines that there is such extensive loss of remaining
teeth or change in supporting tissues that the existing appliance
cannot be made satisfactory. Replacement of a prosthodontic appliance
not provided under a Delta program will be made if it is unsatisfactory
and cannot be made satisfactory.
j) Delta will pay the applicable percentage of the Dentist’s Fee for a
standard cast chrome or acrylic partial denture or a standard complete
denture, up to a maximum fee allowance which is at least the
Prevailing Fee for a standard denture. (A “standard” complete or
partial denture is defined as a removable prosthetic appliance provided
to replace missing natural, permanent teeth and which is constructed
using accepted and conventional procedures and materials.) The
maximum allowance is revised periodically as dental fees change. Any
denture and/or related service for which a charge is made which
exceeds this allowance is an optional service, and the patient is
responsible for the portion of the Dentist’s fee which exceeds the
maximum allowance.
k) Implants (materials implanted into or on bone or soft tissue), or
their removal, are not Benefits under this Contract. However, if
implants are provided in association with a covered prosthodontic
appliance, Delta will allow the cost of a standard complete or partial
denture toward the cost of the implant procedures and prosthodontic
appliances. If Delta makes an allowance toward the cost of such
procedures, Delta will not pay for any replacement placed within five
years thereafter.
l) If an Enrollee selects a more expensive plan of treatment than is
customarily provided, or specialized techniques, an allowance will be
made for the least expensive, professionally acceptable, alternative
treatment plan. Delta will pay the applicable percentage of the lesser
fee and the patient is responsible for the remainder of the Dentist’s
fee. For example: a crown, where a silver filling would restore the
tooth, or a precision denture, where a standard denture would suffice.
m) Diagnostic casts are a benefit only when made in connection with
subsequent covered orthodontic treatment.
Exclusions
Delta covers a wide variety of dental care expenses, but there are some
services for which we do not provide benefits. Enrollees should become
familiar with these services before visiting the dentist. Delta does not
provide benefits for:
1) Services for injuries or conditions which are covered under
Workers’ Compensation or Employer’s Liability Laws.
2) Services which are provided to the Enrollee by any, Federal or State
Government Agency or are provided without cost to the Enrollee
by any municipality, county or other political subdivision, except as
provided in California Health and Safety Code Section 1373(a).
3) Services with respect to congenital (hereditary) or developmental
(following birth) malformations or cosmetic surgery or dentistry for
purely cosmetic reasons, including but not limited to: cleft palate,
upper or lower jaw malformations, enamel hypoplasia (lack of
development), fluorosis (a type of discoloration of the teeth), and
anodontia (congenitally missing teeth).
4) Services for restoring tooth structure lost from wear (abrasion,
erosion, attrition, or abfraction), for rebuilding or maintaining
chewing surfaces due to teeth out of alignment or occlusion, or for
stabilizing the teeth. Such services include but are not limited to:
equilibration and periodontal splinting.
5) Prosthodontic services for any Single Procedure started prior to
the date the person became eligible for such services under
this Contract.
6) Prescribed or applied therapeutic drugs, premedication
or analgesia.
7) Experimental procedures.
8) All hospital costs and any additional fees charged by the Dentist
for hospital treatment.
9) Charges for anesthesia, other than general anesthesia adminis
tered by a licensed Dentist in connection with covered Oral
Surgery services.
10) Extra-oral grafts (grafting of tissues from outside the mouth to
oral tissue).
11) Implants (materials implanted into or on bone or soft tissue) or the
repair or removal of implants or any treatment in conjunction with
implants, except as provided under Limitation (k).
12) Diagnosis or treatment by any method of any condition related to
the temporomandibular (jaw) joint or associated musculature,
nerves and other tissues.
13) Replacement of existing restorations for any purpose other than
restoring active tooth decay.
14) Intravenous sedation, occlusal guards and complete
occlusal adjustment.
15) Orthodontic services, except those provided to eligible
dependent children.
16) Charges for replacement or repair of an orthodontic appliance paid
in part or in full by this program.
Notes
D e l t a P re f e r re d O p t i o n M o n t h l y R a t e s
Non-Voluntary — Employer pays 100% of the cost for the primary and dependent enrollee.
Non-Voluntary
One party
Two party
Three party +
DPO 1
DPO 2
DPO 3
$ 34.41
61.59
99.00
$ 33.12
59.22
95.16
$ 30.84
55.04
86.35
Voluntary Dependents — Employer pays 100% of the cost for the primary enrollee.
Voluntary Dependants
DPO 1
DPO 2
DPO 3
One party
Two party
Three party +
$ 34.41
65.67
108.69
$ 33.12
63.14
104.47
$ 30.84
58.67
94.68
Ineligible industries*
SIC code
The following industries do not qualify for programs
described in this brochure.
Groups with Section 125 programs
Varies
Groups with Flex or Cafeteria plans
Varies
Groups with high turnover
Varies
Current Delta Groups (except for qualified Small Business
Advantage groups§)
Varies
Former Delta Groups†
Varies
Advertising, Misc. not classified
7319
Amusement, Recreation & Entertainment
7900-7999
Associations and Trusts
8600-8699
Beauty & Barber Shops
7231-7241
Community Service Organizations
8300-8499
Co-employment organizations
7361
Ineligible industries (continued)
Dental offices and Dental labs
Employment Agencies
Employee Leasing Agencies
Government-funded Groups
Jewelry Manufacturing
Misc. Business Services
Misc. Services not elsewhere classified
Pacific Life & annuity (PL&A, formerly PMG)
PEO (Professional Employee Organizations)
Public Elementary and High Schools
Real Estate
Seasonal Employees (Christmas/Part-time help)
Seasonal Employees (Agriculture)
Watch, Clock & Jewelry Repair
SIC code
8021, 8072
7361-7363
7361
8300-8499
3911-3915
7389
8999
Varies
7361
8211
6500-6799
no SIC
0761-0783
7631
*Some of these employer classifications may be eligible for Delta Dental programs through specific underwriting activities and custom programs.
Contact a Delta account executive for information.
†Please allow a Delta account executive to provide quotes on former Delta groups.
§Please allow a Delta account executive to provide quotes on qualified Small business Advantage groups.
Need a customized program? Rates for alternate program designs are available by completing and faxing the enclosed Snap! Back
form, or by using our online calculator at www.deltadentalca.org.
Options available are:
•
•
•
•
•
Date of hire or 1st of the month following date of hire eligibility
No waiting period for major services (crowns and cast restorations, prosthodontics)
Deductibles: $25 per patient/$75 per family, $0 deductible (n/a under DPO2)
Maximums: $1,500 per patient per calendar year
Orthodontics: Coverage for children, adults and children $1,000; $1,500; $2,000
separate lifetime maximum per patient
• Four-tier rates
• Rates for employers contributing between 75% and 99% of the cost for the primary enrollee
Rate Guarantee
All rates are valid for a one year contract for groups enrolling no later than December 1, 2004. These rates are for new groups only.
Snap-B
(10/03)
D e l t a P re f e r re d O p t i o n L i m i t a t i o n s a n d E x c l u s i o n s
Limitations
a) Initial examinations, periodic examinations and emergency examinations
are Benefits only when the Dentist is a Delta Dentist with an accepted fee on
file with Delta.
b) Only the first two oral examinations, including office visits for observation
and specialist consultations, or combination thereof, provided to a patient in a
calendar year while he or she is an Enrollee under any Delta program are
Benefits under this program.
c) Delta pays for full-mouth x-rays only after five years have elapsed since
any prior set of full-mouth x-rays was provided under any Delta program.
d) Bitewing x-rays are provided on request by the Dentist, but not more than
twice in any calendar year for children to age 18, or once in any calendar year
for adults ages 18 and over, while the patient is an Enrollee under any Delta
program.
e) Only the first two cleanings, fluoride treatments, or Single Procedures which
include cleaning, or combination thereof, provided to a patient in a calendar
year while he or she is an Enrollee under any Delta program are Benefits under
this program.
f) Sealant Benefits include the application of sealants only to permanent first
molars up to age nine and second molars up to age 14 if they are without caries
(decay), or restorations on the occlusal surface. Sealant Benefits do not include
the repair or replacement of a sealant on any tooth within three years of its
application.
g) Direct composite (resin) restorations are Benefits on anterior teeth and
the facial surface of bicuspids. Any other posterior direct composite (resin)
restorations are optional services and Delta’s payment is limited to the cost of
the equivalent amalgam restorations.
h) Crowns, Jackets, Inlays, Onlays, or Cast Restorations are Benefits on the
same tooth only once every five years while the patient is an Enrollee under any
Delta program, unless Delta determines that replacement is required because
the restoration is unsatisfactory as a result of poor quality of care, or because
the tooth involved has experienced extensive loss or changes to tooth structure
or supporting tissues since the replacement of the restoration.
i) Prosthodontic appliances that were provided under any Delta program,
including but not limited to fixed bridges and partial or complete dentures, will
be replaced only after five years have passed, unless Delta determines that there
is such extensive loss of remaining teeth or change in supporting tissues that
the existing appliance cannot be made satisfactory. Replacement of a
prosthodontic appliance not provided under a Delta program will be made if it
is unsatisfactory and cannot be made satisfactory.
j) Delta will pay the applicable percentage of the Dentist’s Fee for a standard
cast chrome or acrylic partial denture or a standard complete denture, up to a
maximum fee allowance which is at least the Prevailing Fee for a standard
denture. (A “standard” complete or partial denture is defined as a removable
prosthetic appliance provided to replace missing natural, permanent teeth and
which is constructed using accepted and conventional procedures and
materials.) The maximum allowance is revised periodically as dental fees
change. Any denture and/or related service for which a charge is made which
exceeds this allowance is an optional service, and the patient is responsible for
the portion of the Dentist’s fee which exceeds the maximum allowance.
k) Implants (materials implanted into or on bone or soft tissue), or their
removal, are not Benefits under this Contract. However, if implants are provided
in association with a covered prosthodontic appliance, Delta will allow the cost
of a standard complete or partial denture toward the cost of the implant
procedures and prosthodontic appliances. If Delta makes an allowance toward
the cost of such procedures, Delta will not pay for any replacement placed
within five years thereafter.
l) If an Enrollee selects a more expensive plan of treatment than is
customarily provided, or specialized techniques, an allowance will be made for
the least expensive, professionally acceptable, alternative treatment plan. Delta
will pay the applicable percentage of the lesser fee and the patient is
responsible for the remainder of the Dentist’s fee. For example: a crown, where
a silver filling would restore the tooth, or a precision denture, where a standard
denture would suffice.
m) Diagnostic casts are a benefit only when made in connection with
subsequent covered orthodontic treatment.
Exclusions
Delta covers a wide variety of dental care expenses, but there are some services
for which we do not provide benefits. Enrollees should become familiar with
these services before visiting the dentist. Delta does not provide benefits for:
1) Services for injuries or conditions which are covered under Workers’
Compensation or Employer’s Liability Laws.
2) Services which are provided to the Enrollee by any, Federal or State
Government Agency or are provided without cost to the Enrollee by any
municipality, county or other political subdivision, except as provided in
California Health and Safety Code Section 1373(a).
3) Services with respect to congenital (hereditary) or developmental
(following birth) malformations or cosmetic surgery or dentistry for purely
cosmetic reasons, including but not limited to: cleft palate, upper or lower
jaw malformations, enamel hypoplasia (lack of development), fluorosis (a
type of discoloration of the teeth), and anodontia (congenitally missing
teeth).
4) Services for restoring tooth structure lost from wear (abrasion, erosion,
attrition, or abfraction), for rebuilding or maintaining chewing surfaces due
to teeth out of alignment or occlusion, or for stabilizing the teeth. Such
services include but are not limited to: equilibration and periodontal
splinting.
5) Prosthodontic services for any Single Procedure started prior to the date the
person became eligible for such services under this Contract.
6) Prescribed or applied therapeutic drugs, premedication or analgesia.
7) Experimental procedures.
8) All hospital costs and any additional fees charged by the Dentist for
hospital treatment.
9) Charges for anesthesia, other than general anesthesia administered by a
licensed Dentist in connection with covered Oral Surgery services.
10) Extra-oral grafts (grafting of tissues from outside the mouth to
oral tissue).
11) Implants (materials implanted into or on bone or soft tissue) or the repair or
removal of implants or any treatment in conjunction with implants, except
as provided under Limitation (k).
12) Diagnosis or treatment by any method of any condition related to the
temporomandibular (jaw) joint or associated musculature, nerves and
other tissues.
13) Replacement of existing restorations for any purpose other than restoring
active tooth decay.
14) Intravenous sedation, occlusal guards and complete occlusal adjustment.
15) Orthodontic services, except those provided to eligible dependent
children.
16) Charges for replacement or repair of an orthodontic appliance paid in part
or in full by this program.
/kCall your broker, participating general
agent or one of these Delta sales offices:
100 First Street
San Francisco, CA 94105
(415) 972-8300
(415) 972-8466 (fax)
P.O. Box 3370
Cerritos, CA 90703
(562) 403-4040
(562) 924-3172 (fax)
3655 Nobel Drive
Suite 430
San Diego, CA 92122
(858) 458-1340
(858) 458-1828 (fax)
5277 North First Street
Fresno, CA 93710
(559) 221-2282
(559) 243-9493 (fax)
11155 International Drive
Rancho Cordova, CA 95670
(916) 861-2409
(916) 858-0327 (fax)
Visit Delta’s web site at:
www.deltadentalca.org
C (10/03) SN1
©2003 Delta Dental Plan of California