Individual/Family Dental Program

Transcription

1 Individual/Family Dental Program Disclosure Form/Contract Provided by: All Aboard Benefits Ext Delta Dental Insurance Company provides Benefits as a Prepaid Limited Health Service Organization as described in Chapter 636 of the Florida Statutes FLA44 CSO V13

2 DISCLOSURE FORM/CONTRACT ( CONTRACT ) This booklet is a Disclosure Form/Contract ( Contract ) for your DeltaCare USA Individual/Family Dental Program ( Program ). This booklet discloses the terms and conditions of the Program available in Florida. PLEASE READ THE ENTIRE DOCUMENT COMPLETELY AND CAREFULLY. You have a right to review this Contract prior to enrollment. PLEASE READ THE FOLLOWING INFORMATION SO THAT YOU WILL KNOW HOW TO OBTAIN DENTAL SERVICES. YOU MUST OBTAIN DENTAL BENEFITS FROM (OR BE REFERRED FOR SPECIALIST SERVICES BY) YOUR ASSIGNED CONTRACT DENTIST. ADDITIONAL INFORMATION ABOUT YOUR BENEFITS IS AVAILABLE BY CALLING THE CUSTOMER SERVICE DEPARTMENT. Russell L. Aracich Vice President, Sales Southeast FLA44 CSO V13

3 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA ENROLLMENT SECTION Your Full Name: Mailing Address: Date of Birth: INDIVIDUAL/FAMILY DENTAL PROGRAM ENROLLMENT AND PAYMENT AUTHORIZATION FORM Please complete Payment Authorization Section VERY IMPORTANT - PLEASE PRINT LEGIBLY New Enrollment Name Change Facility Change* Last First MIddle Male Female Home Phone: ( ) Street City State & Zip Address Change Add Dependent Remove Dependent Indicate effective date of change: *(Does not pertain to facility change) Month Day Year o 1407 Contract Facility name: Dependent Information Relationship Code* DEPENDENT NAME (include last name only if different than yours) SPOUSE CHILD CHILD BIRTHDATE Mo/Day/Year Please list all dependents to be covered. If additional space is needed attach a separate sheet. on p Codes: Place the following two character code in the first column to designate each dependent as follows: Spouse - SP Domestic Partner - DP Child - CH SEX Male Female Male Female Male Female DEPENDENT STATUS Current New Delete Current New Delete Current New Delete I understand that, if I have indicated on this form that coverage under the Program is to be provided only for the dependent child(ren) named above, I am responsible for payment of the required annual Premium and compliance with all of the provisions and conditions of the Disclosure Form/Contract. FLA44

4 PAYMENT AUTHORIZATION SECTION PROGRAM COST AND PAYMENT OPTION (choose only one) PAYMENT OPTIONS CHECK/MONEY ORDER PAYMENT OPTION Enrollee Premium Please make check or money order payable to the Administrator of Enrollee plus one dependent the Program, Delta Dental Insurance Company. You will have the opportunity to renew prior to the end of the Contract Term to avoid Enrollee plus two or more dependents One-time Enrollment Fee TOTAL $ CREDIT CARD PAYMENT OPTION Additional information regarding Program Costs and Payment Options can be found on page 4 of this booklet. I wish to enroll in the DeltaCare USA Individual/Family Dental Program. I acknowledge that I have read the Disclosure Form/Contract and understand that coverage under the Program is subject to the terms as described in the Disclosure Form/Contract. Please complete Enrollment Section Have you selected a Contract Dentist? If not, we will assign you to a facility near your home. VISA MASTERCARD DISCOVER AMERICAN EXPRESS EXPIRATION DATE NAME AS IT APPEARS ON THE CARD SIGNATURE DATE By signing above you authorize the Administrator to charge your credit card account for the cost of the Program. This authority shall remain in effect to renew your annual enrollment contract term. incomplete, or misleading information is guilty of a felony of the third degree. FLA44 Signature of Applicant Date

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7 Definitions Administrator Applicant Benefits Contract Enrollment and Payment Authorization Form Contract Dentist Contract Orthodontist Contract Specialist Contract Term Copayment Dentist Domestic Partner Effective Date Enrollment and Payment Authorization Form Eligible Dependent FLA44

8 Emergency Services Enrollee Preauthorization Premium Specialist Services Usual Fee We, Us or Our What is the DeltaCare USA Individual/Family Dental Program ("Program")? How to use the Program - Choice of Contract Dentist Enrollment and Payment Authorization Form FLA44

9 Who is eligible for coverage? Renewal, Cancellation and Termination of Benefits How do I enroll? Description of Benefits and Copayments, limitations and exclusions Enrollment and Payment Authorization Form FLA44

10 How much do I pay? plus a one-time enrollment fee of $15.00 plus a one-time enrollment fee of $15.00 Annual plus a one-time enrollment fee of $15.00 Choose a Payment Option Credit Card Payment Option Check/Money Order Payment Option Mailing Instructions Enrollment and Payment Authorization Form FLA44

11 What will my Effective Date be? Emergency Services Specialist Services Schedule A.) Schedule A Schedule B, Orthodontic Limitations and Exclusions What if I need to change Contract Dentists? FLA44

12 Benefits, Limitations and Exclusions Schedule A Schedule B Copayments and Other Charges Schedule A Schedule A Emergency Services Emergency Services Specialist Services Claims for Reimbursement Enrollee Complaint Procedure FLA44

13 Renewal, Cancellation and Termination of Benefits FLA44

14 FLA44

15 Grace Period Extension of Benefits Extension of Benefits Conversion Entire Contract FLA44

16 Governing Law FLA44

17 SCHEDULE A Description of Benefits and Copayments Schedule BEnrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2013 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. CODE DESCRIPTION PAYS When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * limited to 1 series every 24 months FLA44

18 limited to 1 series every 6 months includes office visit, per visit (in addition to other services)... When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * cleaning 1 per 6 month period... cleaning 1 per 6 month period... child to age 19; 1 per 6 month period... child to age 19; 1 per 6 month period limited to permanent molars through age 15. limited to permanent molars through age When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * - Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures FLA44

19 tooth colored... tooth colored... tooth colored.. tooth colored tooth colored... tooth colored.. tooth colored. tooth colored... 1, , , , , , , , , , , , 3... tooth colored 1, 3... tooth colored 1, 3... tooth colored 1, 3... tooth colored 1, 3.. tooth colored 1, 3. tooth colored 1, , , , , , , , , , FLA44

20 anterior primary tooth anterior primary tooth... anterior primary tooth includes canal preparation 2... includes canal preparation 2... base metal post; includes canal preparation... base metal post; includes canal preparation... palliative treatment only limited to permanent molars through age When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * FLA44

21 Root canal 4... Root canal 4... Root canal not covered in conjunction with a hemisection 4... When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * Includes preoperative and postoperative evaluations and treatment under a local anesthetic limited to 4 quadrants during any 12 consecutive months... FLA44

22 limited to 4 quadrants during any 12 consecutive months... limited to 1 treatment in any 12 consecutive months... limited to 1 treatment each 6 month period... 5, , , , , , , , , , FLA44

23 limited to initial placement of interim partial denture /stayplate to replace extracted anterior teeth during healing 5... limited to initial placement of interim partial denture /stayplate to replace extracted anterior teeth during healing , , , , , , , , , , , , , , , , , 8... FLA44

24 , , , , , , , When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * Includes preoperative and postoperative evaluations and treatment under a local anesthetic does not include pathology laboratory procedures FLA44

25 If a Copayment dollar amount is not listed, Enrollee pays 75 percent of the Contract Orthodontist's "filed fees." child or adolescent to age adolescent to age adults, including covered dependent adult children from age 19 to not to be charged with any other consultation procedure(s) includes START- UP FEES, (including initial examination, diagnosis, consultation and initial banding)... When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * FLA44

26 ... includes failed appointment without 24 hour notice - per 15 minutes of appointment time... Replacement is subject to a limitation requiring the existing restoration to be 5+ years old. Base or noble metal is the benefit. If an inlay, onlay or indirectly fabricated post and core is made of high noble metal, an additional fee up to $ per tooth will be charged for the upgrade. Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee of $ A benefit for permanent teeth only. Includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist's facility where the denture was originally delivered. Replacement is subject to a limitation requiring the existing denture to be 5+ years old. Limited to 1 per denture during any 12 consecutive months. Replacement is subject to a limitation requiring the existing bridge to be 5+ years old. FLA44

27 Listed Copayment covers up to 24 months of active orthodontic treatment excluding the services listed for D8999 (Start-up fee), and D8680 (Orthodontic retention). Beyond 24 months, an additional monthly fee not to exceed 75 percent of the Contract Orthodontist's "filed fee" applies. In the event orthodontic treatment is not required or is declined by the Enrollee, a fee of $85.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees. Includes adjustments and/or office visits up to 24 months. After 24 months, a monthly fee not to exceed 75 percent of the Contract Orthodontist's "filed fee" applies. FLA44

28 SCHEDULE B Limitations of Benefits FLA44

29 for a bridge replacing a posterior tooth and and and and and FLA44

30 or FLA44

31 Exclusions of Benefits Schedule ADescription of Benefits and Copayments or FLA44

32 Emergency Services or FLA44

33 Orthodontic Limitations Schedule A Schedule A FLA44

34 and FLA44

35 Orthodontic Exclusions FLA44

36 If you have any questions or need additional information, call: Toll Free (800) Ext In Florida, DeltaCare USA is underwritten and administered by Delta Dental Insurance Company. FLA44 EOC_FLA44_V13_