Delta Dental

The Dental PPO Plan, through Delta Dental, covers a broad range of preventive, diagnostic, basic, major, and orthodontic services. Delta offers two networks: the DPO/PPO network and the DeltaPremier network. The DPO/PPO network offers deep discounts, which means your bill will be as low as possible right from the start. The DeltaPremier network dentists do not discount their fees, but have agreed to not charge more than Delta's allowed amounts for covered services. You may use network dentists from either network. Network dentists will file claims to Delta on your behalf.

When you are seen by a non-network dentist, their fees may exceed the usual, customary, and reasonable (UCR) guidelines, which is Delta's allowed amount for a covered service. You are responsible for any charges that exceed the UCR limit. You may be required to pay the entire bill first and file a claim for reimbursement.

You may choose to enroll in the dental plan even if you have waived medical coverage, or you may decline dental coverage.

This information here is intended to help you understand the plan and how it works. It is not the official Summary Plan Description. To view the complete Summary Plan Description, please reference the Carrier Booklet and CMSU Wrap SPD.

  

  

Delta Dental Plan Benefit Summary

The plan pays the same benefit level for covered dental charges regardless of the provider you use. Your out-of pocket cost may be less when you use network dentists because they agree to charge negotiated fees. Non-network dentists, on the other hand, have not agreed to negotiated rates, so your share of the charges will generally be greater when you receive care outside the network.

DENTAL PLAN AT-A-GLANCE
Plan Provision
Choice of Provider	The provider of your choice
Annual Deductible	$100 per person/$300 per family
Annual Maximum Benefit	$2,000 per person Preventive, diagnostic, and orthodontic care do not count toward your annual maximum benefit, so your benefit goes farther
Covered Services
Preventive & Diagnostic Care:  -Routine exams (two per year)  -Cleanings (three per year)  -Fluoride application for children to age 19 (two per year)  -Bitewing x-rays (one per year for adults, two per year for children to age 19)  -Sealants for children to age 19 (one every three years) Additional Benefits during pregnancy: The plan will pay for additional services to help improve  oral health during pregnancy. The additional services each calendar year include: one additional oral examination and either one additional routine cleaning or one additional periodontal scaling and root planing per quadrant. You or your dentist must provide written confirmation of your pregnancy when the claim is submitted.	Network: 100% (deductible waived) Non-network: 100% of UCR (deductible waived)   Preventive and diagnostic care do not count toward your annual maximum benefit
Basic Restorative Care: fillings, one complete x-ray series every 12 months, simple extractions and oral surgery, root canal therapy, general anesthesia, periodontics (except surgery), and endodontics.	Network: 80% after deductible Non-network: 80% of UCR after deductible
Major Restorative Care: crowns, dentures, bridges, dental implants, inlays, onlays, periodontal surgery, complex oral surgery, and surgery for impacted teeth. Replacement for bridges, crowns, and dentures once every seven years.	Network: 50% after deductible Non-network: 50% of UCR after deductible
Orthodontic Care for Children and Adults: diagnostic procedures (x-rays, casts and treatment plan), appliance therapy and active treatment per month after the first month. Orthodontic care does not count toward your annual maximum benefit	Network: 50% (deductible waived) Non-network: 50% of UCR (deductible waived) $2,000 lifetime maximum benefit

  

How the Plan Works

The PPO Network
Choosing Your Dentist
How Charges Are Paid
Customer Service
Predetermining Benefits

  

The following information will help you understand and use the plan so that you maximize your benefits.

  

The PPO Network

With the Dental PPO Plan, you have the freedom to go to any dentist for dental care. The benefit level is the same regardless of the provider you use. Your out-of-pocket cost may be less when you use network dentists because those providers agree to charge negotiated fees.

When you need dental care, you choose who to see:

DPO/PPO NETWORK DENTISTS	DELTAPREMIER NETWORK DENTISTS	NON-NETWORK DENTISTS
• No claim forms • Discounted fees, resulting in lower out-of-pocket costs • DPO/PPO dentists will never charge you more than Delta's allowed amounts	• No claim forms • DeltaPremier dentists will never charge you more than Delta's allowed amounts	• Claim forms may be required • Non-network dentists may charge you more than Delta's allowed amounts-you are responsible for all such extra charges in addition to any applicable coinsurance you pay

  

Choosing Your Dentist

When you enroll, you may use any dentist, including those listed in the directory of providers. You may access the dental provider directory via the Internet at Delta Dental's website. You may also call the Delta Dental toll-free directory service at 800-427-3237.

When you need care, call a dentist from the directory to schedule an appointment and identify yourself as a PPO participant. Show your dental ID card at your appointment. Remember, with the PPO, you always have the freedom to use any dentist you choose. However, your share of your health care costs will be lowest when you use a PPO provider.

  

How Charges Are Paid

The Deductible

The annual deductible is the amount you pay in eligible expenses before the plan pays any benefits. There is no deductible for preventive and diagnostic services, but each person must pay a $100 deductible each year before the plan begins to cover basic or major services.

The family deductible is $300. Once met, all individuals covered under the plan will be considered to have met their deductible for the year. The family deductible can be satisfied when:

• three family members have met their individual deductible, or
• several family members incur eligible expenses that, when added together, total the family deductible amount-even if none of the individuals have met their individual deductible.

The maximum amount of eligible expenses that one individual may apply toward the family deductible is $100.

  

Annual Maximum Benefits

Plan payments for basic and major services are limited to a maximum of $2,000 a year for each covered family member. Preventive, diagnostic, and orthodontic care do not count toward your annual maximum benefit, so your benefit goes farther.

A separate lifetime limit of $2,000 per person applies to orthodontia services.

  

Covered Dental Charges

The plan covers dental services when the services are provided by a licensed dentist and when they are necessary and customary under the generally accepted standards of dental practice. The plan covers several categories of benefits. If you select a more expensive treatment plan than is customarily provided, or specialized techniques, an allowance will be made for the least costly, professionally acceptable, alternative treatment plan. Delta's benefit will be based on the allowed amount and you will be responsible for the remainder of the dentist's fee that is not covered by the plan. For example, if you receive a crown when a less costly amalgam filling would be acceptable to restoring the tooth, Delta's benefit percentage will be based on the less costly amalgam filling.

  

Network And Non-Network Charges

Payments are made depending on whether you see a network or non-network dentist. Network dentists agree to negotiated rates and non-network dentists do not. When you use a non-network dentist, his or her fees may exceed what Delta Dental recognizes as eligible for your geographic area. You are responsible for any charges over the eligible amount.

In the following example, assume that you have met the $100 individual calendar year deductible and you need a crown. For illustrative purposes, the cost of the crown is $600 for a network dentist. If you go to a non-network dentist, he will charge $750, and the eligible amount under the plan is $630. Your share of the cost using a network dentist would be $300 while your share using a non-network dentist would be $435. Here's how it works:

	NETWORK PROVIDER	NON-NETWORK PROVIDER
Amount the dentist bills	$600	$750
Eligible amount under the plan	$600	$630
What the plan pays	$300 ($600 x 50%)	$315 ($630 x 50%)
What you pay	$300 ($600 - $300)	$435 ($750 - $315)

  

Customer Service

Delta Dental customer service is available to provide you with information and other services you need to make the most of your benefits. If you have any questions or concerns about the plan, you should contact customer service at the number shown on your dental ID card.

  

Predetermining Benefits

If your treatment is expected to cost $300 or more, or you wish to obtain orthodontic care, you can "predetermine benefits" before the treatment starts. With predetermination, you know approximately how much the plan will pay-and how much you will pay.

Your dentist simply needs to send a claim form listing the proposed treatment to Delta Dental. Delta will advise you whether the suggested treatment is appropriate and, if so, how much the plan will pay.

Keep in mind, predetermination is not required and does not guarantee the plan will cover all expenses that you submit.

  

What's Covered

The following information is a summary of covered services. Limitations may apply to these services according to plan provisions.

  

Preventive and Diagnostic Services

The plan will pay 100% of the charges for:

• Routine exams, including office visits for observation and
  specialist consultations, twice per calendar year
• Cleanings three times per calendar year
• Fluoride application for children to 19 three times per year in conjunction with cleanings
• Bitewing x-rays (adults once per year and children to 19 two per year)
• Diagnostic casts once every 24 months only if in connection with orthodontic treatment
• Sealants to permanent teeth without decay for children to 19 once every three years

  

Basic Services

After you meet the annual deductible, the plan pays 80% of the charges for the following services:

• Amalgam fillings (multiple restorations on one surface will be treated as a single filling)
• Composite resin fillings for front teeth and the facial surface of bicuspids
• One complete set of full-mouth x-rays every 12 months
• Space maintainers for children under age 19, once per lifetime; includes all adjustments within six months of installation
• Root canal therapy
• Periodontal maintenance
• Simple extractions and oral surgery
• General anesthesia services and supplies
• Occlusal guards and adjustments
• Endodontics

  

Major Services

After you meet the deductible, the plan pays 50% of the charges for:

• Crowns (covered once every seven years only when a filling cannot restore the tooth)
• Dentures (construction or repair of standard fixed bridges, partial dentures, and complete dentures once every seven years, unless Delta determines that damage to the remaining teeth or supporting tissue warrants a new appliance)
• Dental implants (covered once every five years, removal of implants covered once per tooth)
• Inlays and onlays
• Periodontal surgery
• Complex oral surgery and surgery for impacted teeth

  

Orthodontic Services

Children and adults are eligible for orthodontic care coverage. The plan pays 50% of the eligible charges for covered orthodontic procedures and services that are part of an approved orthodontic treatment plan. The lifetime maximum orthodontic benefit for each covered person is $2,000.

Charges are eligible if they are for the diagnosis and correction of misaligned teeth or abnormal bite. The charge must be a covered expense under the plan.

You must notify Delta Dental in writing before any orthodontic treatment begins. Your dentist will need to provide his or her estimated treatment plan to Delta Dental for review.

The following limitations apply:

• If orthodontic treatment begins before you become eligible for coverage, Delta's payments will begin with the first payment due to the dentist following your eligibility date
• Delta's orthodontics payments will stop when the first payment is due to the dentist following either a loss of eligibility, or if treatment is ended for any reason before it is completed
• X-rays and extractions that might be necessary for orthodontic treatment are not covered by the orthodontic portion of benefits, but may be covered under the preventive and diagnostic portion of the plan
• Delta will pay the applicable percentage of the dentist's fee for a standard orthodontic treatment plan involving surgical and/or non-surgical procedures (if you select specialized orthodontic appliances or procedures for aesthetic reasons, Delta's benefit will be based on the cost of a standard orthodontic treatment plan and you will be responsible for the remainder of the dentist's fee)

  

What's Not Covered

The following expenses are not covered under the Dental PPO Plan:

• Services for injuries or conditions that are covered under Workers' Compensation or employer's liability laws.
• Services that are provided by any federal or state governmental agency or are provided without cost by any municipality, county or other political subdivision, except Medi-Cal benefits.
• Services for cosmetic purposes 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.
• Provisional and/or temporary restorations.
• 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. Examples of such treatment are equilibration and periodontal splinting.
• Any single procedure, bridge, denture, or other prosthodontic service which was started before the patient was covered by this plan.
• Prescribed drugs, or applied therapeutic drugs, premedication, or analgesia.
• Experimenta or investigational procedures.
• Charges by any hospital or other surgical or treatment facility and any additional fees charged by the provider for treatment in any such facility.
• Anesthesia, except for general anesthesia, given by a dentist for covered oral surgery procedures.
• Grafting tissues from outside the mouth to tissues inside the mouth ("extraoral grafts").
• Laboratory processed crowns for patients under age 12.
• Fixed bridges and removable partials for patients under age 16.
• Interim implants and endodontic endosseous implant.
• Indirectly fabricated resin-based inlays/onlays.
• Treatment by someone other than a provider or a person who by law may work under a provider's direct supervision.
• Charges incurred for oral hygiene instruction, a plaque control program, and preventive control programs, or broken appointments.
• Administrative services and ancillary materials.
• Procedures having a questionable prognosis.
• Any tax imposed (or incurred) by a government entity.
• Deductibles, amounts over plan maximums, and services that exceed benefit limitations.

  

Filing Claims

When you use network providers, you do not need to file a claim for benefits. Your network provider will file a claim on your behalf and Delta Dental will pay him or her directly. Keep in mind that you are responsible for paying the annual deductible if applicable to the network provider.

If you use non-network dentists, you may have to pay for the expense and then file your claim for reimbursement. Your claim should be submitted within 90 days after services are rendered, or as soon as reasonably possible—but no later than one year after the date of service. Claims submitted after that date may be denied or reduced, unless you are legally incapacitated.

When you submit a claim, be sure to include:

• Your name, address, and member ID number
• Patient's name and age
• Name and address of the treating dentist
• Diagnosis from the dentist that includes a complete dental chart showing extractions, fillings, or other dental services rendered before the charge for the claim was incurred
• Radiographs, lab, or hospital reports
• Casts, molds, or study models
• An itemized bill which includes the CPT or ADA codes or description of each charge
• The date the dental disease began
• Statement indicating whether or not you are enrolled for coverage under any other health insurance plan or program (if you are enrolled for other coverage, you must include the name of the other carrier(s))

Send your completed claim form and dental bills to:

Delta Dental
P.O. Box 997330
Sacremento, CA 95899-7330

If you do not provide the above information—or any other information needed to confirm your eligibility for coverage—Delta Dental may delay or deny benefit payments.

If you want to have your provider paid directly, you may send a written request to Delta Dental authorizing direct payment. Whenever a law or court order requires payment of dental care expense benefits under the plan to be made to a person or facility other than you, the payment will be made to that person or facility.

Delta Dental will send you an explanation of benefits (EOB) for each claim you or your provider submit. The EOB will show you how much of the expense is the plan's responsibility and how much is yours. In addition, you can view your claims status and claim history online at Delta's website.

If your claim is denied, or partially denied, you have the right to appeal the decision. See Filing Claims under Legal Information for details about appealing your claim.