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.
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 |
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.
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.
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) |
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.
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.