Lincoln County School District

Transcription

1 Lincoln County School District Delta Dental will be your new dental benefits provider effective July 1, Delta Dental has two networks of participating providers: Delta PPO & Delta Premier. Please check the Delta Dental of MO website to see which network your dentist participates in: DeltaDentalMO.com Both networks feature discounts on services; however, the discounts offered by PPO providers are deeper. You will have less out of pocket expenses and your annual maximum will stretch farther if you choose a participating PPO dentist. LOW OPTION If you enroll in this option and choose a PPO dentist: Preventive and Basic services are covered at 100%. You will not pay anything out of pocket until reaching the annual maximum of $500 per person. However, if you choose a Premier or Non-Participating dentist you will be balance billed to make up for the difference between the PPO & Premier discounts; as the Premier discounts are not as deep. HIGH OPTION This option offers a more comprehensive benefit package and adds Major & Orthodontic services to the plan. The annual maximum on the high option increases to $1000 per covered person. PPO & Premier providers will not balance bill and agree to discount their services. Keep in mind that PPO providers offer deeper discounts.

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3 Lincoln County School District Low Plan Participants who choose to visit a Delta Dental Premier dentist or a non-participating dentist will be balance billed. Delta Dental PPO MAC Delta Dental PPO Dentist Delta Dental Premier Dentist Non-Participating Dentist All benefit payments under this plan are based on the lesser of the dentist s usual fees or an amount equal to the Maximum Allowable Charge. Diagnostic and Preventive Services Bitewing x-rays, one set per benefit period Full-mouth x-rays, once in any 36 month period Oral exams, twice per benefit period Periapical x-rays, as required Prophylaxis (cleanings), twice per benefit period Sealants, dependent children under age 16, once in any 36 month period Space maintainers, dependent children under age 16, once in 5 years Fluoride, dependent children under age 16, twice per benefit period Basic Services Fillings Major Services Prosthetics: bridges and dentures, once in 5 years Crowns, inlays and onlays, once in 5 years Bridge & crown repairs & recement Denture repairs & adjustments Emergency palliative treatment Endodontics: root canal filling and pulpal therapy General anesthesia Surgical and Non-Surgical Periodontics: treatment for diseases of gums and bone supporting the teeth Oral surgery Perio maintenance: twice in any benefit period; subject to cleanings frequency limitation Simple & Surgical Extractions Stainless steel crowns Based on applicable PPO Maximum Plan Allowance No balance billing Based on applicable Premier Maximum Plan Allowance Balance Billing is possible Based on applicable Maximum Plan Allowance for nonparticipating dentist - Balance Billing is possible 100% 100% 100% 100% 100% 100% Not covered Not covered Not covered Calendar Year Deductible $0 $0 $0 Calendar Year Benefit Maximum (per person) $500 $500 $500 Dependent Age Limit: 26, end of the month This is intended to be a summary only. If a discrepancy occurs the Summary Plan Document will govern. Please refer to your Summary Plan Description (SPD) for a more complete listing of services including plan limitations and exclusions.

4 Delta Dental gives you the freedom to visit the dentist of your choice and to select any dentist on a treatment by treatment basis. It is important to remember your out-of-pocket costs may vary depending on your choice. You have three options and the information below describes what you can expect depending on whether you receive services from a Delta Dental PPO dentist, a Delta Dental Premier dentist or a non-participating dentist. In PPO Network 1. Delta Dental PPO Network Comprised of a select panel of dentists, over 268,000 dental offices participate in the Delta Dental PPO program. Delta Dental will provide the highest level of benefits (see benefit highlights) for covered services when care is received from a Delta Dental PPO dentist. These dentists agree to: Accept payment based on the applicable PPO Maximum Plan Allowance reducing your out-of-pocket expenses. Submit dental claims for members and abide by Delta s policies. Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta Dental pays the dentist directly. Your out-of-pocket expenses will be lowest when you see a Delta Dental PPO dentist. In Premier Network 2. Delta Dental Premier Network Comprised of over 341,000 participating dental offices, Delta Dental Premier offers you greater access to dentists while still offering the advantages of a network. These dentists have participating agreements with Delta Dental which require them to: Accept payment based on the applicable Premier Maximum Allowable Charge which means you will be responsible for the difference between the applicable Premier fee schedule (or, if less, the Dentist s usual fee) and the Maximum Allowable Charge. Submit dental claims for members and abide by Delta s policies. Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta Dental pays the dentist directly. If your dentist is not a Delta Dental PPO dentist but is a Delta Dental Premier dentist, your benefit will be based on the Premier benefit level; however, you will receive the cost control and claims filing advantages noted above. Non-Participating Dentist 3. Non-participating Dentist If you receive services from a non-participating dentist (does not participate in either Delta Dental network) benefits for covered services are based on the applicable Maximum Plan Allowance for non-participating dentists : You will be responsible for filing your own claim forms. Delta Dental s benefit payment will be made directly to you. Benefit payments will be based on Delta Dental s Maximum Allowable Charge. You will be responsible for the difference between the dentist s charge and Delta Dental s Maximum Allowable Charge. Non-participating dentists may balance bill you up to their entire submitted amount. You are responsible for filing your own claim and for paying the non-participating dentist s total fee. Locating a Participating Dentist To determine if your dentist participates with Delta Dental or to select a participating dentist in your area: Ask your dentist if he or she participates in the Delta Dental PPO or Delta Dental Premier program Search on-line at or Call Delta Dental Customer Service at

5 Lincoln County School District High Plan Delta Dental PPO Dentist Delta Dental Premier Dentist Non-Participating Dentist Delta Dental PPO Diagnostic and Preventive Services Bitewing x-rays, one set per benefit period Full-mouth x-rays, once in any 36 month period Oral exams, twice per benefit period Periapical x-rays, as required Prophylaxis (cleanings), twice per benefit period Sealants, dependent children under age 16, once in any 36 month period Space maintainers, dependent children under age 16, once in 5 years Fluoride, dependent children under age 16, twice per benefit period Basic Services Emergency palliative treatment Endodontics: root canal filling and pulpal therapy Fillings Surgical and Non-Surgical Periodontics: treatment for diseases of gums and bone supporting the teeth Oral surgery Perio maintenance: twice in any benefit period; subject to cleanings frequency limitation Simple and surgical extractions Major Services Prosthetics: bridges and dentures, once in 5 years Crowns, inlays and onlays, once in 5 years Bridge & crown repairs & recement Denture repairs & adjustments General anesthesia Stainless steel crowns Orthodontic Services (for dependent children under age 19) Calendar Year Deductible (applies to Basic and Major Services) Based on applicable PPO Maximum Plan Allowance No balance billing Based on applicable Premier Maximum Plan Allowance No balance billing Based on applicable maximum plan allowance for nonparticipating dentist - Balance billing is possible 100% 100% 100% 80% 80% 80% 50% 50% 50% 50% 50% 50% $50 individual $150 family limit $50 individual $150 family limit $50 individual $150 family limit Calendar Year Benefit Maximum (per person) $1,000 $1,000 $1,000 Orthodontic Lifetime Maximum (per eligible dependent) $1,000 $1,000 $1,000 Dependent Age Limit: 26, end of the month This is intended to be a summary only. If a discrepancy occurs the Summary Plan Document will govern. Please refer to your Summary Plan Description (SPD) for a more complete listing of services including plan limitations and exclusions. Orthodontic treatments covered by the prior carrier and in progress on the original effective date of the employer s group contract with Delta Dental will be covered. Benefits provided by the prior carrier will be subtracted from the lifetime maximum available from Delta Dental.

6 Delta Dental gives you the freedom to visit the dentist of your choice and to select any dentist on a treatment by treatment basis. It is important to remember your out-of-pocket costs may vary depending on your choice. You have three options and the information below describes what you can expect depending on whether you receive services from a Delta Dental PPO dentist, a Delta Dental Premier dentist or a non-participating dentist. In PPO Network 1. Delta Dental PPO Network Comprised of a select panel of dentists, over 268,000 dental offices participate in the Delta Dental PPO program. Delta Dental will provide the highest level of benefits (see benefit highlights) for covered services when care is received from a Delta Dental PPO dentist. These dentists agree to: Accept payment based on the applicable PPO Maximum Plan Allowance reducing your out-of-pocket expenses. Submit dental claims for members and abide by Delta s policies. Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta Dental pays the dentist directly. Your out-of-pocket expenses will be lowest when you see a Delta Dental PPO dentist. In Premier Network 2. Delta Dental Premier Network Comprised of over 341,000 participating dental offices, Delta Dental Premier offers you greater access to dentists while still offering the advantages of a network. These dentists have participating agreements with Delta Dental which require them to: Accept payment based on the applicable Premier Maximum Plan Allowance which means no balance billing on any charges that exceed Delta s contracted amount. Submit dental claims for members and abide by Delta s policies. Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta Dental pays the dentist directly. If your dentist is not a Delta Dental PPO dentist but is a Delta Dental Premier dentist, your benefit will be based on the Premier benefit level; however, you will receive the cost control and claims filing advantages noted above. Non-Participating Dentist 3. Non-participating Dentist If you receive services from a non-participating dentist (does not participate in either Delta Dental network) benefits for covered services are based on the applicable Maximum Plan Allowance for non-participating dentists : You will be responsible for filing your own claim forms. Delta Dental s benefit payment will be made directly to you. Benefit payments will be based on Delta s maximum plan allowance. You will be responsible for the difference between the dentist s charge and Delta maximum plan allowance. Your out-of-pocket expenses may be more when you use a non-participating dentist. Locating a Participating Dentist To determine if your dentist participates with Delta Dental or to select a participating dentist in your area: Ask your dentist if he or she participates in the Delta Dental PPO or Delta Dental Premier program Search on-line at or Call Delta Dental Customer Service at

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9 P.O. Box 8690; St. Louis, MO or Group Name New Application for Coverage I do not wish to enroll. Complete Section 1, 2, and 4. COBRA - Complete Sections Change/Subscriber Authorization Form Section 1 1, 2, 4 and the COBRA item in and 4 must be completed. Section 2 and 3, Section 3 if applicable. complete as applicable for change requested. If applicable: Group#/Sublocation# - - High Option Division/Sublocation Low Option SECTION 1 EMPLOYEE INFORMATION Employee Last Name: First Name: Sex: M Social Security No. Alternate ID Number * Birth Date (mm/dd/yyyy): - / / Street Address: City: State: Zip Code: F Coverage Effective Date: / / Check here if this is a new address. Employee Hire Date: / / Marital Status: Single Married Divorced Widowed A. Does your spouse have any other group dental coverage? Yes No B. If yes to A, are you covered by your spouse's plan? Yes No C. If yes to A, are your dependents covered by your spouse's plan? Yes No D. If yes to A, is the other group dental coverage through a retiree plan? Yes No E. If yes to B or C, provide the name of your spouse's dental plan * For employer groups who utilize Alternate ID numbers, the assigned group number is the first four digits of the Alternate ID. You are still required to submit your SSN on the application for claims processing purposes. SECTION 2 SPOUSE AND DEPENDENT INFORMATION Please complete for spouse/dependents to be enrolled or cancelled. Use a 2nd form for additional dependents if needed. Enroll Spouse - Last Name First Name Cancel Birth Date (mm/dd/yyyy): / / Sex MF Enroll Dependent #1 - Last Name First Name M F Cancel Birth Date (mm/dd/yyyy): / / Relationship: Child Other Enroll Dependent #1 - Last Name First Name M F Cancel Birth Date (mm/dd/yyyy): / / Relationship: Child Other Enroll Dependent #3 - Last Name First Name M F Cancel Birth Date (mm/dd/yyyy): / / Relationship: Child Other Enroll Dependent #4 - Last Name First Name M F Cancel Birth Date (mm/dd/yyyy): / / Relationship: Child Other IMPORTANT: For court ordered dependents, legal documentation must be attached. If your dependent meets the qualifications for full-time student status, necessary documentation is required. DDPM E/C CONTINUED ON NEXT PAGE. No action requested can be taken without your signature.

10 SECTION 3 COVERAGE TYPE SELECTION/REASON FOR CHANGE Select appropriate coverage type: Employee Only Coverage Employee and Spouse Family Employee and Child/Children Name Change: From: Last Name: First Name: To: Last Name: First Name: Reason for Change: All changes must be made within 31 days of the qualifying event. Additions: Cancellations: Effective Date of Addition: / / Effective Date of Cancellation: / / Birth Death Marriage Employee terminated on / / Adoption (attach legal documentation) Divorce Court ordered dependent (attach documentation) Dependent reached student/dependent maximum age Annual Open Enrollment Retired Other (describe) Transfer Membership: Effective Date of Transfer / / From: To: Group#/Sublocation# Group#/Sublocation# Division/Sublocation Division/Sublocation COBRA Membership: If new COBRA participant was previously covered as a dependent of another membership, please list that covered employee's social security number and name: Social Security No. Last Name: First Name: - - SECTION 4 I represent that the information I have provided on this form is complete and accurate. I request the group coverage to which I am entitled, or may become entitled, under the provision of the Membership Certificate/Master Policy issued by Delta Dental of Missouri. I authorize the proper deductions, if any, from my earnings as my contribution toward the cost of this coverage and agree that my employer may act as my agent under this membership. I understand that I cannot transfer my or my dependents' right to receive benefit payments, and I agree to repay promptly any benefit payments to which I or my dependents were not entitled. I also authorize any dentist or other provider of care to furnish Delta Dental of Missouri any necessary information regarding care or treatment of myself or any covered dependents. I understand that courses of dental treatment which began before my effective date may not be covered. Please note that coverage is subject to the limitations, exclusions, and waiting periods contained in the group contract. Employee's Signature: Date: No action requested can be taken without your signature above.