Kaiser Permanente and Delta Dental Dental Program for Kaiser Permanente FEHBP Enrollees You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. Kaiser Permanente and Delta Dental of Colorado recognize that good oral health is an important part of your overall health. Your enrollment in a Kaiser Permanente FEHBP option gives you and your family two ways to maintain good oral health: a preventive dental benefit administered by Delta Dental included as part of your High Option or Standard Option benefits, and a separate optional plan, which you may be eligible to purchase for an additional premium.
2015 Preventive Dental Care Plan Procedure List DIAGNOSTIC/PREVENTIVE SERVICES Diagnostic Services PPO Premier and D0120 Periodic oral evaluation 100% 100% D0140 Limited oral evaluation problem focused 100% 100% D0150 Comprehensive oral evaluation 100% 100% D0160 Detailed and extensive oral evaluation problem focused 100% 100% D0180 Comprehensive periodontal evaluation 100% 100% D0210 Intraoral complete series of radiographic images 100% 100% D0220 Intraoral periapical 1 st radiographic image 100% 100% D0230 Intraoral periapical each additional radiographic image 100% 100% D0240 Intraoral occlusal radiographic image 100% 100% D0270 Bitewing single radiographic image 100% 100% D0272 Bitewings 2 radiographic images 100% 100% D0274 Bitewings 4 radiographic images 100% 100% D0277 Vertical bitewings 7 to 8 radiographic images 100% 100% D0330 Panoramic radiographic image 100% 100% D0340 Cephalometric radiographic image 100% 100% D0460 Pulp vitality tests 100% 100% Preventive Services D1110 Prophylaxis adult 100% 100% D1120 Prophylaxis child age 0 14 100% 100% D1206 Topical application of fluoride varnish 100% 100% D1208 Topical application of fluoride 100% 100% D1351 Sealant per tooth to age 15 100% 100% D1510 Space maintainer fixed unilateral 100% 100% D1515 Space maintainer fixed bilateral 100% 100% Adjunctive Services D9110 Palliative (emergency) treatment of pain minor procedures 100% 100% D9310 Consultation diagnostic service provided by a dentist or physician other than requesting dentist or physician 100% 100%
2015 Buy Up Dental Care Plan Procedure List BASIC SERVICES Minor Restorative Services PPO Premier and D2140 Amalgam 1 surface, primary or permanent 80% 50% D2150 Amalgam 2 surfaces, primary or permanent 80% 50% D2160 Amalgam 3 surfaces, primary or permanent 80% 50% D2161 Amalgam 4 or more surfaces, primary or permanent 80% 50% D2330 Resin-based composite 1 surface, anterior 80% 50% D2331 Resin-based composite 2 surfaces, anterior 80% 50% D2332 Resin-based composite 3 surfaces, anterior 80% 50% D2335 Resin-based composite 4 or more surfaces or involving incisal angle 80% 50% D2391 Resin-based composite 1 surface, posterior 80% 50% D2392 Resin-based composite 2 surfaces, posterior 80% 50% D2393 Resin-based composite 3 surfaces, posterior 80% 50% D2394 Resin-based composite 4 or more surfaces, posterior 80% 50% Oral Surgery D7140 Extraction erupted tooth or exposed root 80% 50% D7210 Surgical removal of erupted tooth 80% 50% D7220 Removal of impacted tooth soft tissue 80% 50% D7230 Removal of impacted tooth partially bony 80% 50% D7240 Removal of impacted tooth completely bony 80% 50% D7241 Removal of impacted tooth completely bony with unusual surgical complications 80% 50% D7250 Surgical removal of residual tooth roots (cutting procedure) 80% 50% Endodontics D3220 Therapeutic pulpotomy primary tooth, excluding final restoration 80% 50% D3310 Root canal therapy anterior (excluding final restoration) 80% 50% D3320 Root canal therapy bicuspid (excluding final restoration) 80% 50% D3330 Root canal therapy molar (excluding final restoration) 80% 50% D3346 Retreatment of previous root canal therapy anterior 80% 50% D3347 Retreatment of previous root canal therapy bicuspid 80% 50% D3348 Retreatment of previous root canal therapy molar 80% 50% D3410 Apicoectomy anterior 80% 50%
2015 Buy Up Dental Care Plan Procedure List BASIC SERVICES (CONTINUED) PPO Premier and D3421 Apicoectomy bicuspid 80% 50% D3425 Apicoectomy molar (first root) 80% 50% Periodontics D4210 Gingivectomy or gingivoplasty per quadrant 80% 50% D4211 Gingivectomy or gingivoplasty 1 3 teeth per quadrant 80% 50% D4240 Gingival flap procedure, including root planing per quadrant 80% 50% D4241 Gingival flap procedure, including root planing 1 3 teeth per quadrant 80% 50% D4260 D4261 Osseous surgery per quadrant (including flap entry and closures) Osseous surgery 1 3 teeth per quadrant (including flap entry and closures) 80% 50% 80% 50% D4263 Bone replacement graft first site in quadrant 80% 50% D4264 Bone replacement graft each additional site in quadrant 80% 50% D4341 Periodontal scaling and root planing per quadrant 80% 50% D4342 Periodontal scaling and root planing 1 3 teeth per quadrant 80% 50% D4910 Periodontal maintenance procedures following active therapy (periodontal prophylaxis) 80% 50% MAJOR SERVICES PPO Premier and D2740 Crown porcelain/ceramic substrate D2750 Crown porcelain fused to high noble metal D2751 Crown porcelain fused to predominantly base metal D2752 Crown porcelain fused to noble metal D2780 Crown 3/4 cast high noble metal D2781 Crown 3/4 cast predominantly base metal D2782 Crown 3/4 cast noble metal D2790 Crown full cast high noble metal D2791 Crown full cast predominantly base metal D2792 Crown full cast noble metal D2920 Recement crown
2015 Buy Up Dental Care Plan Procedure List MAJOR RESTORATIVE SERVICES (CONTINUED) PPO Premier and D2930 Prefabricated stainless steel crown primary tooth D2940 Protective restoration D2950 Core buildup, including any pins when required D2951 Pin retention per tooth, in addition to restoration D2952 Post and core in addition to crown, indirectly fabricated D2953 Each additional indirectly fabricated post same tooth D2954 Prefabricated post and core in addition to crown D2957 Each additional prefabricated post same tooth Implant Surgical Services D3460 Endodontic endosseous implant D6010 Surgical placement of implant body: endosteal implant D6013 Surgical placement of mini implant D6040 Surgical placement: eposteal implant D6050 Surgical placement: transosteal implant D6052 Semi-precision attachment abutment D6055 Connecting bar implant supported or abutment supported D6056 Prefabricated abutment includes modification and placement D6057 Custom fabricated abutment includes placement D6100 Implant removal, by report Implant Restorative Services D6053 Implant/abutment supported removable denture for completely edentulous arch D6054 Implant/abutment supported removable denture for partially edentulous arch D6058 Abutment supported porcelain/ceramic crown D6059 Abutment supported porcelain fused to metal crown (high noble metal) D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)
2015 Buy Up Dental Care Plan Procedure List MAJOR RESTORATIVE SERVICES (CONTINUED) PPO Premier and D6061 Abutment supported porcelain fused to metal crown (noble metal) D6062 Abutment supported cast metal crown (high noble metal) D6063 Abutment supported cast metal crown (predominantly base metal) D6064 Abutment supported cast metal crown (noble metal) D6065 Implant supported porcelain/ceramic crown D6066 Implant supported porcelain fused to metal crown (titanium, titanium allow, high noble metal) D6067 Implant supported metal crown (titanium, titanium allow, high noble metal) D6068 Abutment supported retainer for porcelain/ceramic FPD D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) D6072 Abutment supported retainer for cast metal FPD (high noble metal) D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) D6074 Abutment supported retainer for cast metal FPD (noble metal) D6075 Implant supported retainer for ceramic FPD D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) D6077 Implant supported retainer for cast metal FPD (titanium, titanium allow, or high noble metal) D6078 Implant/abutment supported fixed denture for completely edentulous arch D6079 Implant/abutment supported fixed denture for partially edentulous arch D6094 Abutment supported crown (titanium) D6194 Abutment supported retainer crown for FPD (titanium)
2015 Buy Up Dental Care Plan Procedure List MAJOR SERVICES (CONTINUED) Other Implant Related Services PPO Premier and D5875 Modification of removable prosthesis following implant surgery D6090 Repair implant supported prosthesis, by report D6092 Recement implant/abutment supported crown D6093 Recement implant/abutment supported fixed partial denture D6095 Repair implant abutment, by report D6190 Radiographic/surgical implant index, by report Fixed Prosthetics D6210 Pontic cast high noble metal D6211 Pontic cast predominantly base metal D6212 Pontic cast noble metal D6240 Pontic porcelain fused to high noble metal D6241 Pontic porcelain fused to predominantly base metal D6242 Pontic porcelain fused to noble metal D6750 Crown porcelain fused to high noble metal D6751 Crown porcelain fused to predominantly base metal D6752 Crown porcelain fused to noble metal D6790 Crown full cast high noble metal D6791 Crown full cast predominantly base metal D6792 Crown full cast noble metal Removable Prosthetics D5110 Complete denture upper D5120 Complete denture lower D5130 Immediate denture upper D5140 Immediate denture lower D5213 D5214 Upper partial denture-metal base with resin saddles (including any conventional clasps, rests and teeth) Lower partial denture metal base with resin saddles (including any conventional clasps, rests and teeth)
2015 Buy Up Dental Care Plan Procedure List MAJOR SERVICES (CONTINUED) PPO Premier and D5510 Repair broken complete denture base D5520 Replace missing/broken teeth-complete denture (each tooth) D5630 Repair/replace broken clasp partial denture D5640 Replace tooth on partial denture per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5750 Reline complete upper denture (laboratory) D5751 Reline complete lower denture (laboratory)
Preventive Dental Care (Delta Dental PPO SM plus Premier) With your FEHBP medical coverage through Kaiser Permanente, you receive dental coverage for preventive services. With Delta Dental PPO plus Premier, you may visit the dentist of your choice, but you will pay nothing for covered procedures when you visit a participating Delta Dental dentist. * Your Preventive Dental Care plan covers 100% of charges for the following procedures (refer to your preventive procedure list to view all covered services): Oral exams Full-mouth and bitewing X-rays Cleanings Fluoride (child and adult) Delta Dental Buy Up Plan If you would like more extensive coverage for you and your family, you may purchase separate coverage through Delta Dental s Buy Up Plan for an additional monthly premium. Coverage includes the following types of services (refer to your Buy Up procedure list to view all covered services): Fillings Crowns Implants Periodontal cleanings Extractions Root canals Dentures Buy Up Plan Monthly Cost Employee: $19.87 Employee + 1: $39.74 Employee + family: $79.48 Rates are effective 1/1/15 12/31/15 You MUST be enrolled in either the High or Standard Option medical plans to purchase the dental Buy Up plan. How to Enroll No enrollment form is necessary for the Preventive Dental Care Plan. You will be automatically signed up for that plan with your enrollment in Kaiser Permanente s medical plan. If you wish to purchase the additional coverage, please complete the enclosed Delta Dental enrollment and payment authorization form. *This is a brief description of the features of Kaiser Foundation Health Plan Inc. s Buy Up and Preventive Dental Care plans. Before making a final decision, please read the plan s federal brochure. All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal (RI 73-019) brochure.
How Coverage Works Your Preventive Dental Care plan and the Buy Up plan work differently. To help you choose the right coverage for your needs, this chart provides helpful information on how your benefits work. You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. Preventive Dental Care Plan Buy Up Plan Premium Cost to Patient Calendar-year Maximum Calendar-year Deductible Coverage included with your medical plan premium No annual maximum for diagnostic and preventive services None Covered Services PREVENTIVE SERVICES Monthly premium applies $1,000 $50 for individual $150 for family Oral Exams Cleanings 100% covered X-rays BASIC SERVICES Fillings Simple Extractions Endodontics Not covered under the Preventive (Root Canals) Dental Care plan Periodontics (Gum Disease Treatment) MAJOR SERVICES (12-month waiting period for new enrollees) Implants Not covered under the Preventive 50% covered Dental Care plan Crowns Dentures This is a brief description of the features of the Kaiser Foundation Health Plan. Before making a final decision, please read the plan s federal brochure (RI 73-019). All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure. Contact Delta Dental of Colorado Customer Service 1-800-610-0201 (toll-free) customer_service@ddpco.com Dentist Search & Eligibility deltadentalco.com Claims Submission PO Box 173803 Denver, CO 80217-3803 100% covered under Preventive Dental Care Plan 80% covered when treated by Delta Dental PPO dentist 50% covered when treated by Delta Dental Premier or out-of-network dentist
Delta Dental PPO SM plus Premier With the Delta Dental PPO plus Premier plan, you and your family may visit any licensed dentist but will receive the greatest out-of-pocket savings if you see a Delta Dental PPO dentist. Participating dentists file claims directly with Delta Dental and accept Delta Dental s reimbursement in full. You are responsible only for your deductible and coinsurance (as determined by your plan), as well as any charges for non-covered services up to Delta Dental s approved amount. If you choose to see an out-of-network dentist, you will incur additional out-of-pocket expenses, and you will be billed the total amount the dentist charges (called balancebilling). When you see a Delta Dental PPO or Premier dentist, you are protected from balance-billing. Advantages of the Delta Dental PPO plus Premier plan Savings: Delta Dental PPO dentists offer subscribers the greatest savings. And you will still save money if you need a service that is not covered. Non-covered services will be billed at a discounted rate if you go to a PPO dentist. Choice: If you choose to visit a Premier dentist, you will still save money because Premier dentists also accept discounted fees (however, discounts are not as great as if you see a PPO dentist). Network: Delta Dental s dual network has nearly 90,000 PPO providers and 145,000 Premier providers nationwide. Looking for a dentist? Concerned about costs? PPO dentists offer you the greatest savings. Service: Porcelain Crown (Benefit illustration only. Example assumes deductible has been met.) Network Greatest Patient Savings Protected from balance-billing Delta Dental PPO Dentist Delta Dental Premier Dentist Least Patient Savings Not protected from balance-billing Out-of-Network Dentist Procedure Cost $1,000 $1,000 $1,000 Maximum Dentist Can Charge Patient Maximum Dentist Can Charge Insurance (MPA)* $710 $950 Unlimited $710 $950 $660 Benefit Percentage 50% Delta Dental Pays $355 $475 $330 You Pay $355 $475 $670 To find a participating dentist or to see if your current dentist is in the network, visit deltadentalco.com and click on the Find a Dentist search tool. You can also contact our customer relations department, Monday Friday 8 a.m. to 6 p.m. MT, at 1-800-610-0201 (toll-free) or customer_service@ddpco.com. *The maximum a dentist can charge your insurance company is called the Maximum Plan Allowance (MPA). The MPA for an out-of-network dentist is always lower than in-network MPA. Delta Dental pays a portion of the MPA only, which exposes you to balance-billing from an out-of-network dentist.
Today s Date: Enrollment Form & Payment Authorization Kaiser Permanente FEHBP Enrollees Subscriber Information (complete for all enrollments/changes/updates) Subscriber Name (Last) (First) (Middle Initial) Subscriber Social Security Number Subscriber Date of Birth (MM-DD-YYYY) Mailing Address City State Zip Code Male Female Subscriber Phone Number (including area code) Subscriber Email Address Select Coverage: Employee Only Employee and Family Please list all dependents. All fields are required. Add Delete Last Name First Name SSN Date of Birth M F Plan Enrollment To enroll, complete this form, including premium payment information and authorization. Return the completed form to: Delta Dental of Colorado, PO Box 5468, Denver, CO 80217-5468. Or fax it to: 303-741-9160. Automatic Premium Payment (APP) Authorization Your payment will be automatically deducted from your bank account on the 27th of each month. Complete this form and be sure to sign it before you submit it. If this form is received by the 20th, your plan effective date will be the first of the month following receipt. Name on Account Name of Bank Account Type: Checking Savings Routing Number (first nine digits on check) Account Number Automatic Premium Payment (APP) Agreement I hereby authorize Delta Dental of Colorado or its agent to initiate debit entries to my checking or savings account as indicated. I acknowledge that payment for the upcoming period will be deducted from my account on the 27th of the previous month (initial payment will be deducted upon receipt of enrollment form). If the charge is declined for any reason, Delta Dental will attempt to charge me again on the 27th of the following month. If the charge is still declined, they will immediately terminate my contract for nonpayment of premium, effective as of the last day of the grace period. This authorization is to remain in full force and effect until Delta Dental of Colorado or its agent receives thirty (30) days notice from me of its cancellation. The notification must be sent to Delta Dental of Colorado, PO Box 5468, Denver, CO 80217-5468. Signature of Authorized Account Holder Requested Effective Date (Must be first of the month) KP_FEHBP_EnrollForm_072214