Introduction
Taking care of your teeth is an important but often overlooked aspect of good health. Depending on where you live, the Company gives you a choice of up to two different dental plans to help you make a decision that’s right for you and your family.
Dental Plan Options
The Delta Dental Plan offers the most flexibility. You can see any dentist you choose, but you pay less if you see a DeltaPreferred Option (DPO) dentist or a Delta network dentist. You choose which dentist you want to see each time you need dental care.
The SafeGuard Plan is a prepaid dental plan. It works like a medical HMO—you select a primary dentist who coordinates all of your dental care. You do not pay deductibles nor are you required to fill out any paperwork. You pay a copay based on the type of service provided, but many basic services and all diagnostic and preventive services are covered at 100%.
The plan provides a limited orthodontia benefit. Certain maximums apply.
An “At-A-Glance” chart of your dental options is on the next page, followed by detailed information about the plans.
Waive Cov erage Option
You may choose to waive Company dental coverage.
Your
Dental Options At-A-Glance
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DELTA |
SAFEGUARD |
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Delta |
Delta Network Dentist |
Any Dentist |
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Who Provides Care |
All care provided by a DPO dentist |
All care provided by a Delta network dentist |
Care provided by any dentist you choose |
All care coordinated by your primary dentist |
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Cost |
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Annual Deductible |
$100 |
None |
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Annual Benefit Maximum |
$1,000/person |
None |
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Lifetime Benefit
Maximum for Orthodontia |
$500 per person |
None |
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Diagnostic and Preventive
Services |
Plan pays 100% with no deductible |
Plan pays 50% of negotiated fees with no deductible |
Plan pays 50% with no deductible2 |
Plan pays 100% |
|
Basic Services |
After deductible, plan pays 80% |
After deductible, plan pays 50%1 |
After deductible, plan pays 50%2 |
Plan pays 100% for most services |
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Major Services |
After deductible, plan pays 60% |
After deductible, plan pays 50%1 |
After deductible, plan pays 50%2 |
Each procedure has a scheduled copay |
|
Prosthodontic Services |
After deductible, plan pays 60%1 |
After deductible, plan pays 50%1 |
After deductible, plan pays 50%2 |
|
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Orthodontics |
Plan pays 50% of
covered expenses with no deductible, |
You pay minimum $1,050 copay. Additional charges depend on treatment plan |
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1 Based on either negotiated fee or Delta’s maximum fee allowance–whichever is lower.
2 Based on either usual and customary expenses
of Delta dentists or Delta’s maximum fee allowance–
whichever is lower.
When
Coverage Begins
For Yourself
Your coverage will become effective on the first day of the month following your date of eligibility, provided that you have returned a signed enrollment form within 31 days of becoming eligible (or the first day of the calendar year following the annual open enrollment period). If you do not return your enrollment form within 31 days, your next chance to enroll for dental coverage will be during the annual open enrollment period in the fall, unless you have a qualified status change (see the About Your Benefits Program section in this binder for details).
If You’re Absent from Work
If you are absent from work for any reason, including illness, disability or leaves of absence, you are considered to be an inactive employee. If you are an inactive employee on the date coverage is scheduled to begin, your coverage will become effective on the first day of the month after you return to work. If you return to work on the first day of the month, then coverage will begin on that day.
For Your Dependents
Dental coverage for your dependents begins when your coverage begins, provided that you have returned a signed enrollment form within 31 days of becoming eligible. If you do not return your enrollment form within 31 days, your next chance to enroll your dependents for dental benefits will be during the annual open enrollment period in the fall.
If you get married, your new spouse and eligible stepchildren are eligible for coverage the first of the month following your marriage date. You must enroll your new dependents within 31 days following the date of marriage.
You may also add your domestic partner and eligible
dependents of your domestic partner for coverage any time during the year. In
addition to completing a Family Status Change form, you must complete and
submit the Affidavit of Domestic Partnership to Employee Benefits.
If you or your covered spouse/domestic partner have a baby,
adopt a child, have a child placed for adoption or become the court-appointed
legal guardian, you may enroll your new child within 31 days of the birth, date
of adoption, placement for adoption or the date the court establishes legal
guardianship.
You may choose not to enroll your newborn in the dental plan until a future annual open enrollment period. The dental plans require that all eligible dependents be enrolled, if any eligible dependents are enrolled, unless the dependent is covered under another dental plan, or in the case of a child who has not attained a specific age as specified by the carrier. The dental plan may require proof of other coverage for dependents considered late entrants.
If You’re Enrolled in the Delta Dental Plan
If you elect dependent coverage under the Delta Dental Plan, you are required to enroll all eligible dependents over age four in the plan. You may waive coverage for a dependent only if he or she:
n Is under age four or
n Has coverage elsewhere or
n No dependents are covered.
About
the Delta Dental Plan
How the Plan Works
When you need dental care, you have the option of seeing a DeltaPreferred Option (DPO) dentist, a dentist in the Delta network or any other dentist of your choice. If you see a DPO dentist, you typically pay less than if you see a Delta network dentist or a non-network dentist. This is because DPO dentists have agreed to charge you negotiated fees that are typically lower than those charged by other dentists. This means that your share of the cost (called coinsurance) is usually lower when you use a DPO dentist.
Although you will usually pay more if you see a Delta network dentist, your cost will probably still be less than if you see a non-network dentist. Here is how it works:
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If you receive care from a: |
Your covered expenses are based on: |
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DPO dentist—you will
receive the highest level of benefits |
n The actual fees charged or n
The DPO dentist's negotiated fees on file with
Delta— |
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Delta network
dentist—you will receive a high level of benefits |
n The actual fees charged, n The Delta dentist's negotiated fees on file with Delta or n
Delta's maximum
fee allowance— |
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Non-network dentist—you
will receive the lowest level of benefits |
n The actual fees charged n The usual and customary (U&C)* charges of Delta dentists or n
Delta's maximum fee allowance— If your dentist's fees are higher than Delta's U&C charges, you are responsible for paying the difference. |
*See the following page for information on usual and customary (U&C) charges.
Deductible
Each year you must pay the first portion of
your dental costs, called the deductible.
After you meet your annual deductible—$100 per person or $300 per family—the
plan pays a percentage of your costs for the rest of the year up to the maximum
annual benefit per person. Your costs are determined by which dentist you see.
For preventive, diagnostic and orthodontic services, the deductible does not apply.
Maximum Fee Allowance
The maximum fee allowance for a procedure is the fee that would satisfy the majority of Delta dentists. Some Delta dentists, however, may charge a fee that is higher than the maximum fee allowance. If your charges exceed the maximum fee allowance, you will be required to pay your coinsurance plus the amount over the maximum fee allowance. The maximum fee allowance is revised periodically as dental fees change.
Usual and Customary (U&C) Charges
If you see a dentist who is not in either of the Delta networks, the plan will make payments only toward the usual and customary (U&C) charges or the Delta maximum fee schedule for any type of treatment. If your charges exceed the maximum fee schedule or the U&C limits, you will be required to pay the excess cost. Any amounts in excess of the maximum fee schedule or the U&C charges are not considered covered expenses under the plan. A charge will be considered to be incurred on the date the service is received, rather than on the date the charge is made or billed.
Example
Kelly, Nathan and Alex all need several
fillings for cavities. Kelly decides to visit a DPO dentist for care, Nathan
sees a Delta dentist and Alex goes to see a dentist who is not in either the
DPO or Delta network. Assuming that all three have already met their annual
deductibles, here is what each will pay for the same service:
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Kelly (uses a |
Nathan (uses a Delta |
Alex |
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Total dental fees* |
$500 |
$600 |
$700 |
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U&C charges/filed
fee |
$500 |
$550 |
$600 |
|
Plan pays |
80% (or $400) |
50% (or $275) |
50% of U&C charges |
|
Patient pays |
20% (or $100) |
50% (or $275) |
50% of U&C charges (or $300) plus the amount over the U&C charges not covered by the plan (or $100, $700-$600) |
|
Total out-of-pocket |
$100 |
$275** |
$400 |
* Fees for non-network providers are generally higher than network providers because Delta does not have negotiated rates with non-network providers.
** The dentist waives $50.
This is an example
only. All costs and calculations are estimates.
Predetermination of Benefits
Predetermination of benefits is a way for you and your dentist to estimate, in advance, what benefits the plan will pay for a proposed course of dental treatment. It enables Delta to review your dentist’s proposed treatment plan and resolve any questions before—rather than after—any work has been completed. Predetermination of benefits is recommended for a treatment that is expected to cost $300 or more.
A predetermination does not guarantee payment. It is an estimate of the amount Delta will pay if the patient is eligible and meets all the requirements of the program at the time the planned treatment is completed. Computations are estimates only and are based on what would be payable on the date the Notice of Predetermination is issued if the patient is eligible. Payment will depend on the patient’s eligibility and the remaining annual maximum when completed services are submitted to Delta.
To get a predetermination of benefits, ask your dentist to submit an “Attending Dentists Statement” to Delta. The statement usually includes:
n
Itemized recommended services
n Estimated charges for each service and
n Supporting X-rays and other diagnostic information as required or requested by Delta.
Your dentist can either submit:
n His or her own form or
n The Delta Dental claim form (available from Delta).
Alternative Treatments
Sometimes you have a choice of the type of materials or treatments you receive for a specific dental condition. The plan is designed to help you cover your costs for necessary dental care—not for treatment that is more costly or elaborate than needed.
If two or more dental services are suitable under customary dental practice, the benefit will be based on the least costly procedure or material that will produce a professionally satisfactory result.
Examples of alternative treatments would be if you have a crown put in where a silver filling would restore the tooth or a precision denture where a standard denture would suffice.
Continuity of Care
If you are undergoing a course of treatment and your dentist’s contract with Delta ends, you may continue to receive treatment from that dentist until the treatment is completed.
What Is Cov ered
Diagnostic and Preventive Services
You do not pay a deductible for diagnostic and preventive services. The plan pays the following benefits depending on which dentist you use:
n DPO dentist: The plan pays 100% of covered expenses
n Delta network dentist or non-network dentist: The plan pays 50% of covered expenses.
Diagnostic services include:
n Two oral exams per calendar year
n Bitewing X-rays
– for covered children under age 18—twice in a calendar year
– for covered adults age 18 and older—once in a calendar year.
n Full mouth X-rays once every five years (unless special need is determined)
n Diagnostic casts
n Biopsy/tissue examination
n Emergency treatment and
n Consultation by a specialist.
Preventive services include:
n Two teeth cleanings (oral prophylaxis) per calendar year. (Note: periodontal cleanings, listed below under basic services, also count toward the limit of two teeth cleanings per calendar year)
n Two fluoride treatments per calendar year for children up to age 14
n Space maintainers.
Basic Services
After you meet the deductible, the plan pays the following benefits, depending on which dentist you use:
n DPO dentist: The plan pays 80% of covered expenses
n Delta network dentist or non-network dentist: The plan pays 50% of covered expenses.
Basic services include:
n Oral surgery, including extractions
n Amalgam, synthetic, plastic or resin restorations (fillings) for treatment of cavities (tooth decay)
n Endodontics (treatment of tooth pulp)
n Periodontics (treatment of gums and bones that support teeth). The plan pays a benefit oftwo periodontal cleanings per calendar year. Periodontal cleanings are included in the limitation of two cleanings per calendar year (see prophylaxis listed in Diagnostic and Preventive Benefits)
n Sealants. Sealant benefits include the application of sealants only to permanent first and second molars without decay, without restorations and with the occlusal surface intact, for first molars up to age nine and second molars up to age 14. Sealant benefits do not include the repair or replacement of a sealant on any tooth within three years of its application.
Major Services
After you meet the deductible, the plan pays the following
benefits, depending on which dentist
you use:
n DPO dentist: The plan pays 60% of covered expenses
n Delta network dentist or non-network dentist: The plan pays 50% of covered expenses.
Major Services Include:
n Crowns
n Jackets
n Inlays and onlays and
n Cast restorations.
These services are covered if:
n They are used to treat cavities that cannot be directly restored with amalgam, synthetic, plastic or resin filling
n The tooth receiving treatment has not had another crown, jacket, inlay, onlay or cast restoration within the last five years.
Prosthodontic Services
After you meet the deductible, the plan pays the following benefits, depending on which dentist you use:
n DPO Dentist: The plan pays 60% of covered expenses
n Delta network dentist or non-network dentist: The plan pays 50% of covered expenses.
Prosthodontic services include treatment to replace missing natural teeth (i.e., the construction or repair of fixed bridges, and partial and complete dentures if provided to replace missing, natural teeth). Benefits for prosthodontics are as follows:
n Replacement of existing appliances once every five years, unless Delta determines that an existing appliance cannot be made satisfactory because of an extensive loss of remaining teeth or a change in supporting tissues
n The maximum fee allowance for standard partial or complete dentures made from accepted materials and by conventional methods
n Implants are not a covered benefit. However, Delta will pay 50% of the maximum fee allowance attributable for a standard partial or full denture when the prosthetic appliance is completed. If Delta pays a benefit for an appliance, the plan will not cover replacement for five years following completion of the service.
Orthodontia Cov erage
You and each covered family member are eligible for orthodontic services. The plan pays 50% of covered expenses with no deductible, up to a lifetime maximum of $500 per person. The lifetime maximum benefit for orthodontia is separate from the annual maximum of $1,000 that applies to diagnostic, preventive, basic, major and prosthodontic services.
What Is Not Cov ered
Not all dental services and supplies are
covered by the plan. The following services and supplies are not covered:
n Charges for a procedure that was started before plan coverage became effective
n Charges in excess of covered expenses
n Services or supplies provided by anyone other than a licensed dentist, except for cleaning and scaling of teeth performed by a licensed dental hygienist under the supervision and direction of a licensed dentist, or an X-ray ordered by a dentist
n Charges for more than two oral exams and teeth cleanings (including both regular and periodontic cleanings) in one calendar year
n Charges for more X-rays than allowed under the plan
n Charges for more than two fluoride treatments in one calendar year
n Charges for the replacement or repair of sealants that are less than three years old
n Charges for the replacement of existing dentures or fixed bridgework that is less than five years old, unless it cannot be made serviceable
n Pit and fissure sealants for patients older than 13 years of age
n Services and supplies in connection with temporomandibular joints (TMJ) or associated muscles, nerves or tissues
n Experimental procedures
n Prescribed drugs, premedication or analgesia
n Anesthesia, except for general anesthesia given by a dentist for covered oral surgery procedures
n