Today s businesses need to be flexible reliable and customer-driven That s what you can expect from this dental plan. Delta Dental programs for businesses with 100 to 399 employees.
Your needs are simple. You want a quality dental program that has value written all over it. Excellent accesss to dentists. Strong customer support. And program designs that are flexible after all, every business is unique. Simple, right? Managed Fee-for-Service Program It s a Snap! with Delta Dental. Delta s managed fee-for-service program. Snap! is a portfolio of Delta s most popular Dental programs, each providing maximum value for businesses with 100 to 399 employees. Preferred Provider Program Delta s PPO program. Delta s HMO program administered by Delta affiliate PMI Dental Health Plan.
flexible reliable and customer-driven But what you ll really appreciate about Snap! is it s flexibility. You can quickly and easily customize a Snap! program to fit your needs by going on the web at www.deltadentalca.org. Inside you ll find program designs and rates for our most popular programs. Choose from these programs, or receive a fast quote on a program you ve customized using our available options. It s that simple.
Managed Fee-for-Service Program For Businesses with 100-399 Employees DeltaPremier is Delta Dental s original and most popular fee-for-service product. Why? With DeltaPremier, enrollees have the freedom to choose any licensed dentist, but it is to the enrollee s advantage to choose a Delta dentist There are over 22,000 active Delta dental offices in California (approximately 92% of all California dental offices) DeltaPremier benefits are based on a fee-for-service concept. The percentage of the enrollee s copayment will depend on the treatment received, as shown in the table below Services (or Benefits)* Diagnostic and preventive services (No deductible) such as oral exams, x-rays, cleanings and fluoride treatments opremier 1 Delta s Payment 100% Premier 2 Delta s Payment 80% Other basic services includes fillings, oral surgery, root canals, periodontal treatment and sealants 80% 80% Crowns, cast restorations and prosthodontics includes caps, veneers, dentures ** and bridges 50% 50% Deductible per person, per calendar year (Deductible rollover credit available) $50 per patient $150 per family $50 per patient $150 per family Waiting Period for crowns, cast restorations prosthodontics (Waived for initial enrollees) 12 months 12 months Calendar year maximum, per person $1,000 o $1,000 When an enrollee visits a Delta dentist, Delta guarantees the amount of copayment for covered services. How can Delta guarantee the amount of copayment? It s made possible with Delta s unique filed fee system. Each Delta dentist is required to submit his or her fees for approval in advance The copayment amount is based directly on these pre-negotiated fees. This way, Delta makes sure enrollees never pay a larger portion than what is specified in their program If an enrollee goes to a non-delta dentist, the enrollee will be responsible for the difference between the amount approved by Delta and the amount actually charged by the dentist *Please refer to the enclosed DeltaPremier Limitations and Exclusions section for those services which may not be covered. **Subject to a maximum allowance (please refer to limitation J in the DeltaPremier and DPO limitations and exclusions section).
DeltaPremier and DPO Limitations and Exclusions Limitations a) Initial examinations, periodic examinations and emergency examinations are Benefits only when the Dentist is a Delta Dentist with an accepted fee on file with Delta. b) Only the first two oral examinations, including office visits for observation and specialist consultations, or combination thereof, provided to a patient in a calendar year while he or she is an Enrollee under any Delta program are Benefits under this program. c) Delta pays for full-mouth x-rays only after five years have elapsed since any prior set of full-mouth x-rays was provided under any Delta program. d) Bitewing x-rays are provided on request by the Dentist, but not more than twice in any calendar year for children to age 18, or once in any calendar year for adults ages 18 and over, while the patient is an Enrollee under any Delta program. e) Only the first two cleanings, fluoride treatments, or Single Procedures which include cleaning, or combination thereof, provided to a patient in a calendar year while he or she is an Enrollee under any Delta program are Benefits under this program. f) Sealant Benefits include the application of sealants only to permanent first molars up to age nine and second molars up to age 14 if they are without caries (decay), or restorations on the occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within three years of its application. g) Direct composite (resin) restorations are Benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta s payment is limited to the cost of the equivalent amalgam restorations. h) Crowns, Jackets, Inlays, Onlays, or Cast Restorations are Benefits on the same tooth only once every five years while the patient is an Enrollee under any Delta program, unless Delta determines that replacement is required because the restoration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration. i) Prosthodontic appliances that were provided under any Delta program, including but not limited to fixed bridges and partial or complete dentures, will be replaced only after five years have passed, unless Delta determines that there is such extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a Delta program will be made if it is unsatisfactory and cannot be made satisfactory. j) Delta will pay the applicable percentage of the Dentist s Fee for a standard cast chrome or acrylic partial denture or a standard complete denture, up to a maximum fee allowance which is at least the Prevailing Fee for a standard denture. (A standard complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials.) The maximum allowance is revised periodically as dental fees change. Any denture and/or related service for which a charge is made which exceeds this allowance is an optional service, and the patient is responsible for the portion of the Dentist s fee which exceeds the maximum allowance. k) Implants (materials implanted into or on bone or soft tissue), or their removal, are not Benefits under this Contract. However, if implants are provided in association with a covered prosthodontic appliance, Delta will allow the cost of a standard complete or partial denture toward the cost of the implant procedures and prosthodontic appliances. If Delta makes an allowance toward the cost of such procedures, Delta will not pay for any replacement placed within five years thereafter. l) If an Enrollee selects a more expensive plan of treatment than is customarily provided, or specialized techniques, an allowance will be made for the least expensive, professionally acceptable, alternative treatment plan. Delta will pay the applicable percentage of the lesser fee and the patient is responsible for the remainder of the Dentist s fee. For example: a crown, where a silver filling would restore the tooth, or a precision denture, where a standard denture would suffice. m) Diagnostic casts are a benefit only when made in connection with subsequent covered orthodontic treatment. Exclusions Delta covers a wide variety of dental care expenses, but there are some services for which we do not provide benefits. Enrollees should become familiar with these services before visiting the dentist. Delta does not provide benefits for: 1) Services for injuries or conditions which are covered under Workers Compensation or Employer s Liability Laws. 2) 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 provided in California Health and Safety Code Section 1373(a). 3) 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, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth), and anodontia (congenitally missing teeth). 4) Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), 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 and periodontal splinting. 5) Prosthodontic services for any Single Procedure started prior to the date the person became eligible for such services under this Contract. 6) Prescribed or applied therapeutic drugs, premedication or analgesia. 7) Experimental procedures. 8) All hospital costs and any additional fees charged by the Dentist for hospital treatment. 9) Charges for anesthesia, other than general anesthesia adminis tered by a licensed Dentist in connection with covered Oral Surgery services. 10) Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue). 11) Implants (materials implanted into or on bone or soft tissue) or the repair or removal of implants or any treatment in conjunction with implants, except as provided under Limitation (k). 12) Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves and other tissues. 13) Replacement of existing restorations for any purpose other than restoring active tooth decay. 14) Intravenous sedation, occlusal guards and complete occlusal adjustment. 15) Orthodontic services, except those provided to eligible dependent children. 16) Charges for replacement or repair of an orthodontic appliance paid in part or in full by this program.
Notes
DeltaPremier Monthly Rates Non-Voluntary Employer pays 100% of the cost for the primary and dependent enrollee. Non-Voluntary Program 1 Program 2 One party $ 36.43 $ 32.55 Two party 65.26 58.08 Three party + 105.33 90.32 Voluntary Dependents Employer pays 100% of the cost for the primary enrollee. Voluntary Dependants Program 1 Program 2 One party $ 36.43 $ 32.55 Two party 69.58 61.91 Three party + 115.67 98.99 Ineligible industries* SIC code The following industries do not qualify for programs described in this brochure. Groups with Section 125 programs Groups with Flex or Cafeteria plans Groups with high turnover Current Delta Groups (except for qualified Small Business Advantage groups ) Former Delta Groups Advertising, Misc. not classified 7319 Amusement, Recreation & Entertainment 7900-7999 Associations and Trusts 8600-8699 Beauty & Barber Shops 7231-7241 Community Service Organizations 8300-8499 Co-employment organizations 7361 Ineligible industries (continued) SIC code Dental offices and Dental labs 8021, 8072 Employment Agencies 7361-7363 Employee Leasing Agencies 7361 Government-funded Groups 8300-8499 Jewelry Manufacturing 3911-3915 Misc. Business Services 7389 Misc. Services not elsewhere classified 8999 Pacific Life & annuity (PL&A, formerly PMG) PEO (Professional Employee Organizations) 7361 Public Elementary and High Schools 8211 Real Estate 6500-6799 Seasonal Employees (Christmas/Part-time help) no SIC Seasonal Employees (Agriculture) 0761-0783 Watch, Clock & Jewelry Repair 7631 *Some of these employer classifications may be eligible for Delta Dental programs through specific underwriting activities and custom programs. Contact a Delta account executive for information. Please allow a Delta account executive to provide quotes on former Delta groups. Please allow a Delta account executive to provide quotes on qualified Small business Advantage groups. Need a customized program? Rates for alternate program designs are available by completing and faxing the enclosed Snap! Back form, or by using our online calculator at www.deltadentalca.org. Options available are: Date of hire or 1st of the month following date of hire eligibility No waiting period for major services (crowns and cast restorations, prosthodontics) Deductibles: $25 per patient/$75 per family, $0 deductible Maximums: $1,500 per patient per calendar year Orthodontics: Coverage for children, adults and children $1,000; $1,500; $2,000 separate lifetime maximum per patient Four-tier rates Rates for employers contributing between 75% and 99% of the cost for the primary enrollee Rate Guarantee All rates are valid for a one year contract for groups enrolling no later than December 1, 2004. These rates are for new groups only. Snap-A (10/03)
DeltaPremier Limitations and Exclusions Limitations a) Initial examinations, periodic examinations and emergency examinations are Benefits only when the Dentist is a Delta Dentist with an accepted fee on file with Delta. b) Only the first two oral examinations, including office visits for observation and specialist consultations, or combination thereof, provided to a patient in a calendar year while he or she is an Enrollee under any Delta program are Benefits under this program. c) Delta pays for full-mouth x-rays only after five years have elapsed since any prior set of full-mouth x-rays was provided under any Delta program. d) Bitewing x-rays are provided on request by the Dentist, but not more than twice in any calendar year for children to age 18, or once in any calendar year for adults ages 18 and over, while the patient is an Enrollee under any Delta program. e) Only the first two cleanings, fluoride treatments, or Single Procedures which include cleaning, or combination thereof, provided to a patient in a calendar year while he or she is an Enrollee under any Delta program are Benefits under this program. f) Sealant Benefits include the application of sealants only to permanent first molars up to age nine and second molars up to age 14 if they are without caries (decay), or restorations on the occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within three years of its application. g) Direct composite (resin) restorations are Benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta s payment is limited to the cost of the equivalent amalgam restorations. h) Crowns, Jackets, Inlays, Onlays, or Cast Restorations are Benefits on the same tooth only once every five years while the patient is an Enrollee under any Delta program, unless Delta determines that replacement is required because the restoration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration. i) Prosthodontic appliances that were provided under any Delta program, including but not limited to fixed bridges and partial or complete dentures, will be replaced only after five years have passed, unless Delta determines that there is such extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a Delta program will be made if it is unsatisfactory and cannot be made satisfactory. j) Delta will pay the applicable percentage of the Dentist s Fee for a standard cast chrome or acrylic partial denture or a standard complete denture, up to a maximum fee allowance which is at least the Prevailing Fee for a standard denture. (A standard complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials.) The maximum allowance is revised periodically as dental fees change. Any denture and/or related service for which a charge is made which exceeds this allowance is an optional service, and the patient is responsible for the portion of the Dentist s fee which exceeds the maximum allowance. k) Implants (materials implanted into or on bone or soft tissue), or their removal, are not Benefits under this Contract. However, if implants are provided in association with a covered prosthodontic appliance, Delta will allow the cost of a standard complete or partial denture toward the cost of the implant procedures and prosthodontic appliances. If Delta makes an allowance toward the cost of such procedures, Delta will not pay for any replacement placed within five years thereafter. l) If an Enrollee selects a more expensive plan of treatment than is customarily provided, or specialized techniques, an allowance will be made for the least expensive, professionally acceptable, alternative treatment plan. Delta will pay the applicable percentage of the lesser fee and the patient is responsible for the remainder of the Dentist s fee. For example: a crown, where a silver filling would restore the tooth, or a precision denture, where a standard denture would suffice. m) Diagnostic casts are a benefit only when made in connection with subsequent covered orthodontic treatment. Exclusions Delta covers a wide variety of dental care expenses, but there are some services for which we do not provide benefits. Enrollees should become familiar with these services before visiting the dentist. Delta does not provide benefits for: 1) Services for injuries or conditions which are covered under Workers Compensation or Employer s Liability Laws. 2) 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 provided in California Health and Safety Code Section 1373(a). 3) 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, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth), and anodontia (congenitally missing teeth). 4) Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), 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 and periodontal splinting. 5) Prosthodontic services for any Single Procedure started prior to the date the person became eligible for such services under this Contract. 6) Prescribed or applied therapeutic drugs, premedication or analgesia. 7) Experimental procedures. 8) All hospital costs and any additional fees charged by the Dentist for hospital treatment. 9) Charges for anesthesia, other than general anesthesia administered by a licensed Dentist in connection with covered Oral Surgery services. 10) Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue). 11) Implants (materials implanted into or on bone or soft tissue) or the repair or removal of implants or any treatment in conjunction with implants, except as provided under Limitation (k). 12) Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves and other tissues. 13) Replacement of existing restorations for any purpose other than restoring active tooth decay. 14) Intravenous sedation, occlusal guards and complete occlusal adjustment. 15) Orthodontic services, except those provided to eligible dependent children. 16) Charges for replacement or repair of an orthodontic appliance paid in part or in full by this program.
/kcall your broker, participating general agent or one of these Delta sales offices: 100 First Street San Francisco, CA 94105 (415) 972-8300 (415) 972-8466 (fax) P.O. Box 3370 Cerritos, CA 90703 (562) 403-4040 (562) 924-3172 (fax) 3655 Nobel Drive Suite 430 San Diego, CA 92122 (858) 458-1340 (858) 458-1828 (fax) 5277 North First Street Fresno, CA 93710 (559) 221-2282 (559) 243-9493 (fax) 11155 International Drive Rancho Cordova, CA 95670 (916) 861-2409 (916) 858-0327 (fax) Visit Delta s web site at: www.deltadentalca.org C (10/03) SN1 2003 Delta Dental Plan of California