Dental for Everyone Platinum PPO
A. Enrollment and Eligibility
Individuals who are 18 years of age, and their eligible dependents (unmarried children from birth to age 26). Individuals 65 years of age and over are eligible to enroll, and will be charged the same rate as those enrollee’s under 65.
B. Your Effective Date
Plan effective dates are always the 1st of the month. If the enrollment form and payment information are received by the 19th of the month, coverage will become effective on the 1st of the following month. Incomplete enrollment forms or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured under the Plan until you receive your certificate of insurance.
C. How does the Plan work?
As long as you meet the plan's general eligibility requirements and pay the applicable premium, your acceptance is automatic. This plan contains waiting periods that must be satisfied before coverage is available for services.
D. Annual Deductible & Calendar Year Maximums
The annual deductible is the amount of covered dental charges incurred by an insured person or on behalf of your insured dependent before Delta Dental starts paying benefits. The annual deductible of $50 will apply to each insured person for Type 1, 2, and 3, while Type 4 (Orthodontia Procedures) requires a $100 lifetime deductible. The Calendar Year Maximum is the maximum amount payable for all eligible dental expenses in any calendar year. The Calendar Year Maximum for this policy is $1,500 for each insured person.
E. Choice of Provider
Delta offers Delta Dental Premier Plan (Indemnity Plan) or a Delta Dental PPO plan. The Premier Plan rates are based on Delta Dental’s Premier network. Both Premier and Non-Delta Dental dentists are reimbursed on Usual, Reasonable and Customary (UCR) charges. The Premier dentist will file the claim with Delta Dental and will not balance bill. PPO coverage rates are based on Delta Dental’s PPO network. Benefits for all dentists are based on Delta Dental’s reduced PPO fee schedule. PPO dentists will file the claim with Delta Dental. There is no balance billing for PPO dentists.
F. Specialty Care/ Specialty Referrals
Specialty Care can be utilized and the benefits will be applied based on the type of service needed, provided the waiting periods have been satisfied.
G. Emergency Dental Services
Emergency services can be utilized and the benefits will be applied based on the type of service needed, provided the waiting periods have been satisfied.
H. Coordination of Benefits
This plan will be coordinated with any other group, blanket or franchise plan under which an individual will receive benefits. This helps keep the cost of the plan reasonable.
I. Cancellation Policy
The policy may be canceled with 30 days written notice.
J. Termination of Policy
Coverage terminates on the earliest of the following dates:
- The last day of the month in which you cease to be eligible for coverage.
- The last day of the month in which your dependent is no longer a dependent, as defined.
- Subject to the grace period, the last day of the month for which a premium has been paid by you or on your behalf.
- The date the policy ends.
K. Exclusions/ Limitations
LIMITATIONS ON ALL BENEFITS -
Services that are more expensive than the form of treatment customarily provided under accepted dental practice standards are called "Optional Services." Optional Services also include the use of specialized techniques instead of standard procedures. For example:
- A crown where a filling would restore the Tooth;
- A precision denture/partial where a standard denture/partial could be used;
- An inlay/onlay instead of an amalgam restoration; Or
- a composite/resin restoration instead of an amalgam restoration on posterior teeth.
If you receive Optional Services, your Benefits will be based on the lower cost of the customary service or standard practice instead of the higher cost of the Optional Service. You will be responsible for the difference between the higher cost of the Optional Service and the lower cost of the customary service or standard practice.
Delta does not pay Benefits for:
- Services for injuries or conditions which are compensable under workers' compensation or employers' liability laws; 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 such exclusion maybe prohibited by law.
- 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,maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration) of the teeth, and andontia (congenitally missing teeth), except those services provided to newborn children for congenital defect or birth abnormalities or services that may be provided under Orthodontic Benefits.
- Services for restoring tooth structure lost from wear, erosion, or abrasion, 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, periodontal splinting, occlusaladjustment.
- Any Single Procedure started prior to the date the person became covered for such services under this program.
- Prescribed drugs, medication or analgesia.
- Experimental procedures.
- Charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in any such facility.
- Charges for anesthesia, other than by a licensed Dentist for administering general anesthesia in connection with covered oral surgery services.
- Extra oral grafts (grafting of tissues from outside the mouth to oral tissues).
- Services with respect to any disturbance of the temporomandibular joint (jaw joint).
- Services performed by any person other than a Dentist or auxiliary personnel legally authorized to perform services under the direct supervision of a Dentist.
- Replacement of teeth extracted prior to the member's effective date.
This is a general group summary of the features of the Delta Dental Insurance Company plan issued to Benefits Association, Inc. When you purchase the plan you will receive a Certificate of Coverage that details your rights and obligations, as well as those of the insurance company.
This website provides a very brief description of some of the important features of this plan. It is not the insurance contract, nor does it represent the insurance contract. A full description of benefits, exceptions and limitations is contained in the Certificate of Coverage