Plans: Preventive Comprehensive Standard Comprehensive Enhanced Millennium Choice Standard & Enhanced Plans I, II, III & IV Dental Flex Discover
Underwriting Guidelines and Participation Requirements Groups with 20% me of residing outside are subject to underwriting review. Employee-only plans are available f groups of 5+. Standard codination of benefits f small group pooled products. If coverage is waived, a qualifying event must occur to gain coverage unless the group qualifies f an open enrollment. Dental offices/clinics are not eligible. In the following products, a minimum of 5 employees must enroll regardless of the group s size options selected Preventive, Comprehensive Standard, Comprehensive Enhanced F groups with 5-99 Only full-time employees are eligible f a dental plan. Full-time employment is defined as a minimum of 20 hours per week, subject to the employer s practice. Seasonal tempary employees are not eligible. Groups of any size may request domestic partners coverage (same-sex and/ opposite sex). The employer may only select one product f all employees. 5-99 Eligible Employees Annual open enrollment f and eligible dependents (spouse and children) of enrolled employees 30 days pri to renewal. Comprehensive Standard and Comprehensive Enhanced feature 80% of all and 80% of eligible dependents not covered under another dental plan must enroll. Preventive Plan features 75% of all and 75% of eligible dependents not covered under another dental plan must enroll. Underwriting Guidelines F Delta Dental Preventive, Comprehensive Standard & Comprehensive Enhanced: Cannot provide coverage f groups in which me of employees are related by blood relation, marriage adoption. Plan I, Plan II, Plan III, Plan IV F groups with 5-9 F groups with 10-99 5-99 Eligible Employees 100% of all and 100% of eligible dependents not covered by another dental plan must enroll. Annual open enrollment if 10 me employees enroll. Enrollment must consist of at least 80% of all and 80% of eligible dependents not covered by another dental plan with a minimum of 10 employees enrolled. Underwriting Guidelines F Plans I, II, III, IV: Cannot provide coverage f groups in which me of employees are related by blood relation, marriage adoption. Millennium Choice - Standard, Enhanced F groups with 5-9 F groups with 10-199 5-199 Eligible Employees 100% of all and 100% of eligible dependents not covered by another dental plan must enroll. Annual open enrollment if 10 me employees enroll. Enrollment must consist of at least 80% of all and 80% of eligible dependents not covered by another dental plan. Underwriting Guidelines F Millennium Choice: Cannot provide coverage f groups in which me of employees are related by blood relation, marriage adoption. In the following products, only 5 employees need to enroll with no other employee dependent participation percentage requirements Dental Flex 5+ Eligible Employees Program Dental Flex Annual open enrollment. A minimum of 5 employees must enroll. F new groups not covered by an existing dental plan, the published waiting periods apply. F groups that have had at least 12 consecutive months of employerpaid comparable basic and maj coverage, all waiting periods are waived. F new groups with at least 12 consecutive months of comparable voluntary basic and maj coverage: If 90% of the enrolling group is covered under the previous dental plan, all waiting periods are waived. Underwriting Guidelines F Dental Flex: Cannot provide coverage f groups in which me of employees are related by blood relation, marriage adoption. satisfied to coincide with the group s open enrollment. Lower premiums are offered if the employer s contribution is greater. Discover (Non-Netwk Program) A minimum of 5 employees must enroll. 5+ Eligible Employees Underwriting Guidelines F Discover: Lower premiums are offered if the employer s contribution is greater. Groups with me employees who are related by blood relation, marriage adoption are subject to review with appropriate documentation, including wage and tax statements and Articles of Incpation.
Preventive, Comprehensive Standard, Comprehensive Enhanced 5-99 Eligible Employees Netwk(s) Employer Contribution Employer Selection(s) Delta Dental Premier Contributy Voluntary Participation Guidelines Apply 1 Plan with choice of deductible, annual maximum and thodontic coverage F groups with 5-99 Annual open enrollment f and eligible dependents (spouse and children) of enrolled employees 30 days pri to renewal. Comprehensive Standard and Comprehensive Enhanced feature 80% of all and 80% of eligible dependents not covered under another dental plan must enroll. Preventive Plan feature 75% of all and 75% of eligible dependents not covered under another dental plan must enroll. Underwriting Guidelines f Delta Dental Preventive, Comprehensive Standard & Comprehensive Enhanced: Cannot provide coverage f groups in which me of employees are related by blood relation, marriage adoption. Service Description Benefit Preventive Plan Comprehensive Plan Standard Enhanced Other Preventive Services Complex Maj Restative Services Oral evaluations/checkups, x-rays, dental cleanings, fluide treatments Space maintainers 100% Basic Restative Care and Services: f emergencies Basic extraction of erupted tooth exposed root Complex Surgical Extractions: Surgical removal of erupted tooth, impacted tooth and tooth roots Other Complex Oral Surgical Procedures Alveoloplasty, vestibuloplasty, frenulectomy, tooth reimplantation Adjunctive General Services: Intravenous conscious and IV sedation with complex surgical services Pulpal therapy, root canal therapy, pulpotomy Complex Endodontic Services: Hemisection, apicoectomy Non-surgical periodontal care Surgical periodontal care 100% 100% 100% 80% after deductible 100% N/A N/A 80% N/A 80% Posteri composite resins N/A alternate treatment Inlays alternate treatment alternate treatment Deductible Onlays, crowns and crown repairs Restative cast post and ce buildup, including pins and posts f crowns Removable prosthetic services - dentures and partials N/A N/A (**) Fixed prosthetic services - bridges (**) Restative cast post and ce buildup, including pins and posts f bridge N/A Repairs - removable and fixed prosthetic service Implants (**) Per person/per family (calendar year) No deductible f diagnostic and preventive services None $25/$75 $50/$150 $25/$75 $50/$150 Co-payment $10 per office visit N/A N/A Per person/per calendar year 5 to 49 enrolled employees $1,000 $1,000 $1,000 $1500 50 me enrolled employees $1,250 Optional Orthodontic Coverage A minimum of 5 enrolled employees required. Available only f dependent children, age 8-18 N/A $1,000 lifetime maximum Members who receive services from non-delta Dental netwk dentists are covered at the same benefit level as those who see Delta Dental Premier netwk participating dentists. However, because non-delta Dental netwk dentists are not under contractual obligation, they may balance bill members f the amount not reimbursed under the plan. Alternate Treatment: Plan member receives the amalgam benefit f the least costly, commonly perfmed course of treatment. The plan member is responsible f the balance of the treatment cost. **Missing-tooth exclusion applies during the first 24 months of coverage. Claim payments are subject to review. We strongly recommend a pre-estimate f implants and all maj services. F exact benefits and current rates,contact your Delta Dental Connect Sales Representative: (651) 406-5920 (800) 906-5250. DeltaDentalMN.g
Millennium Choice - Standard, Enhanced 5-199 Eligible Employees Netwk(s) Employer Contribution Employer Selection(s) Delta Dental PPO Delta Dental Premier F groups with 5-9 F groups with 10-199 Contributy Voluntary Participation Guidelines Apply 1 Plan, dual option, with choice of deductible and thodontic coverage 100% of all and 100% of eligible dependents not covered by another dental plan must enroll. Annual open enrollment if 10 me employees enroll. Enrollment must consist of at least 80% of all and 80% of eligible dependents not covered by another dental plan with a minimum of 10 employees enrolled. Underwriting Guidelines F Millennium Choice: Cannot provide coverage f groups in which me of employees are related by blood relation, marriage adoption. Service Description Benefit Standard Benefit Plan Enhanced Benefit Plan Oral evaluations/checkups, x-rays, dental cleanings, fluide treatments Plan Option I Plan Option II Plan Option I Plan Option II PPO DDP DDP PPO DDP DDP 100% 80% 100% 100% 80% 100% Other Preventive Services Space maintainers 90% * 80%* 100% 80% 100% Basic Restative Care and Services: f emergencies Basic extraction of erupted tooth exposed root Complex Surgical Extractions: Surgical removal of erupted tooth, impacted tooth and tooth roots Other Complex Oral Surgical Procedures Alveoloplasty, vestibuloplasty, frenulectomy, tooth reimplantation Adjunctive General Services: Intravenous conscious and IV sedation with complex surgical services Pulpal therapy, root canal therapy, pulpotomy Complex Endodontic Services: Hemisection, apicoectomy Non-surgical periodontal care Surgical periodontal care 90% 80% 90% 80% 100% 80% 100% 80% N/A N/A N/A 80% 90% 80% 90% 80% 80% 80% N/A N/A N/A 80% 80% 80% 80% 80% Complex Maj Restative Services Posteri composite resins alternate treatment Inlays alternate treatment alternate treatment Crowns and crown repairs Restative cast post and ce buildup, including pins and posts f crowns Removable prosthetic services - dentures and partials N/A N/A N/A ** ** ** Fixed prosthetic services - bridges ** ** ** Restative cast post and ce buildup, including pins and posts f bridge Repairs - removable and fixed prosthetic service N/A N/A N/A Implants ** ** ** Deductible Optional Orthodontic Coverage Per person/per family (calendar year) No deductible f diagnostic and preventive services none $25/$75 none $25/$75 Per person / per calendar year $2,000 $2,000 $1,000 $2,000 $2,000 $1,000 A minimum of 10 enrolled employees required. Available only f dependent children, age 8-18 $1,000, $1,500 $2,000 lifetime maximum PPO - PPO Members who receive services from Delta Dental PPO netwk dentist receive the highest cost savings. Members who receive services from Delta Dental Premier netwk dentists receive less cost savings that those who see Delta Dental PPO netwk dentists. Members who receive service from non-delta Dental netwk dentists are covered at the same slightly lower benefit levels as those who see Delta Dental Premier netwk dentists. However, because non-delta Dental netwk dentists are not under contractual obligation, they may balance bill members f the amount not reimbursed under the plan. Alternate Treatment: Plan members receives the amalgam benefit f the least costly, commonly perfmed course of treatment, The plan member is responsible f the balance of the treatment cost. *Subject to deductible, **Missing-tooth exclusions applies during the first 24 months of coverage. Claim payments are subject to review. We strongly recommend a pre-estemate f implants and all maj services. F exact benefits and current rates, contact your Delta Dental Connect Sales Representative: (651) 406-5920 (800) 906-5250. DeltaDentalMN.g DDP - Delta Dental Premier
Plan I, Plan II, Plan III, Plan IV, 5-99 Eligible Employees Netwk(s) Employer Contribution Employer Selection(s) Delta Dental PPO Delta Dental Premier Contributy Voluntary Participation Guidelines Apply 1 Plan with choice of deductible and thodontic coverage F groups with 5-9 F groups with 10-99 Service Description Benefit 100% of all and 100% of eligible dependents not covered by another dental plan must enroll. Annual open enrollment if 10 me employees enroll. Enrollment must consist of at least 80% of all and 80% of eligible dependents not covered by another dental plan with a minimum of 10 employees enrolled. Underwriting Guidelines F Plans I, II, III, IV: Cannot provide coverage f groups in which me of employees are related by blood relation, marriage adoption. Oral evaluations/checkups, x-rays, dental cleanings, fluide treatments Basic Restative Care and Services: f emergencies Plan I Plan II Plan III Plan IV PPO DDP PPO DDP PPO DDP PPO DDP 100% 80% 100% 80% 100% 80% 100% 80% 90% 100% 80% 80% Basic extraction of erupted tooth exposed root 100% 100% 80% 80% Complex Surgical Extractions: Surgical removal of erupted tooth, impacted tooth and tooth roots 80% 80% Adjunctive General Services: Intravenous conscious and IV sedation with complex surgical services 90% 100% 80% 80% Pulpal therapy, root canal therapy, pulpotomy 80% 90% 80% 80% Non-surgical periodontal care 80% 80% 80% 80% Complex Maj Restative Services Surgical periodontal care 80% 80% Posteri composite resins, inlays Onlays, crowns and crown repairs (*) 60% Removable prosthetic services - dentures and partials (**) --------------------------alternate treatment -------------------------- 60% Fixed prosthetic services - bridges (*)(**) 60% Repairs - removable and fixed prosthetic services 60% Implants (**) Deductible Per person/per family (calendar year) No deductible f diagnostic and preventive services none none none Optional Orthodontic Coverage Per person/per calendar year $2,000 $2,000 $2,000 $2,000 $1,250 $1,250 $1,250 $1,250 A minimum of 10 enrolled employees required. Available only f dependent children, age 8-18 choice of $1,000, $1,500 $2,000 lifetime maximum PPO - PPO DDP - Delta Dental Premier Members who receive services from Delta Dental PPO netwk dentists receive the highest cost savings. Members who receive services from Delta Dental Premier netwk dentists receive less cost savings than those who see Delta Dental PPO netwk dentists. Members who receive services from non-delta Dental netwk dentists are covered at the same slightly lower benefit levels as those who see Delta Dental Premier netwk dentists. However, because non- Delta Dental netwk dentists are not under contractual obligation, they may balance bill members f the amount not reimbursed under the plan. Alternate Treatment: Plan member receives the amalgam benefit f the least costly, commonly perfmed course of treatment. The plan member is responsible f the balance of the treatment cost. *Coverage does not include crown bridge services such as buildups, pins, posts ces. ** Missing-tooth exclusion applies during the first 24 months of coverage. Claim payments are subject to review. We strongly recommend a pre-estimate f implants and all maj services. F exact benefits and current rates, contact your Delta Dental Connect Sales Representative: (651) 406-5920 (800) 906-5250. DeltaDentalMN.g
Dental Flex 5+ Eligible Employees Netwk(s) Employer Contribution Employer Selection(s) Delta Dental PPO Delta Dental Premier Contributy Or Voluntary 1 Plan with choice of annual maximum and thodontic coverage Program Dental Flex Annual open enrollment. A minimum of 5 employees must enroll. F new groups not covered by an existing dental plan, the published waiting periods apply. F groups that have had at least 12 consecutive months of employerpaid comparable basic and maj coverage, all waiting periods are waived. F new groups with at least 12 consecutive months of comparable voluntary basic and maj coverage: If 90% of the enrolling group is covered under the previous dental plan, all waiting periods are waived. Underwriting Guidelines F Dental Flex: Cannot provide coverage f groups in which me of employees are related by blood relation, marriage adoption. Lower premiums are offered if the employer s contribution is greater. Service Description Benefits 6 month waiting period unless noted Complex Maj Restative Services 12 month waiting period Deductible Optional Orthodontic Coverage Oral evaluations/checkups, x-rays, dental cleanings, fluide treatments Basic Restative Care and Services: f emergencies Delta Dental PPO Netwk 100% 80% Delta Dental Premier Netwk 80% Out-of-Netwk 80% Basic extraction of erupted tooth exposed root Complex Surgical Extractions: Surgical removal of erupted tooth, impacted tooth and tooth roots Pulpal therapy, root canal therapy, pulpotomy Non-surgical periodontal care Surgical periodontal care Posteri composite resins Onlays, crowns and crown repairs (*) Removable prosthetic services - dentures and partials (*)(**) Fixed prosthetic services - bridges(*)(**) Repairs - removable and fixed prosthetic service Per person/per family (calendar year) No deductible f diagnostic and preventive services $50/$150 $50/$150 $50/$150 Per person / per calendar year $1,000, $1,500 $2,000 $1,000, $1,500 $2,000 $1,000, $1,500 $2,000 A minimum of 10 enrolled employees required. Available only f dependent children, age 8-18. No waiting periods f new groups with at least 12 months of pri thodontic coverage. A 12-month waiting period applies to new groups and new employees without pri thodontic coverage ---------------alternate treatment --------------- $1,000, $1,500 $2,000 lifetime maximum Alternate Treatment Plan member receives the amalgam benefit f the least costly, commonly perfmed course of treatment. The plan member is responsible f the balance of the treatment cost.*coverage does not include crown bridge services such as buildups, pins, posts ces. **Missing tooth exclusion applies during the first 24- months of coverage. Dental Flex Waiting Periods: F new groups not covered an existing dental plan, the published waiting periods apply. F groups that have had at least 12 connective months of employer-paid voluntary basic and maj coverage, all waiting periods are waived. F new groups with at least 12 consecutive months of comparable voluntary basic an maj coverage: If 90% of ht enrolled group is covered under the previous dental plan all waiting periods are waived. F exact benefits and current rates, contact your Delta Dental Connect Sales Representative: (651) 406-5920 (800) 906-5250. DeltaDentalMN.g
Discover (Non-Netwk Program) 5+ Eligible Employees Netwk(s) Employer Contribution Employer Selection(s) No Netwk Contributy Or Voluntary 1 Plan with choice of deductible and annual maximum A minimum of 5 employees must enroll. Underwriting Guidelines F Discover: Lower premiums are offered if the employer s contribution is greater. Groups with me employees who are related by blood relation, marriage adoption are subject to review with appropriate documentation, including wage and tax statements and Articles of Incpation. Service Description Benefit Oral evaluations/checkups, x-rays, dental cleanings, fluide treatments 100% Miscellaneous X-Rays: Full mouth/complete series panamic x-rays, periapical x-rays, occlusal x-rays Basic Restative Care and Services: f emergencies Basic extraction of erupted tooth exposed root Complex Surgical Procedures: Impacted tooth, bony imopaction, alveoloplasty, vestibuloplasty, frenulectomy, tooth reimplementation Adjunctive General Services: Intravenous conscious and IV sedation with complex surgical services Pulpal therapy, root canal therapy, pulpotomy Complex Endodontic Services: Hemisection, apicoectomy Complex Maj Restative Services Non-surgical periodontal care Surgical periodontal care Posteri composite resins, onlyas Inlays alternate treatment Crowns and crown repairs Restative cast post and ce buildup, including pins and posts f crows Removable prosthetic services - dentures and partials Fixed prosthetic services - bridges Orthodontics Restative cast post and ce buildup, including pins and posts f bridge Repairs - removable and fixed prosthetic service Automatically included as long as ten me employees are enrolled in the plan. Available only f dependent children, age 8-18 Deductible Per person, per calendar year. Applies to all services none $25 Per person, per calendar year. Includes thodontic services, if eligible. $500 $750 Alternate Treatment Plan member receives the amalgam benefit f the least costly, commonly perfmed course of treatment. The plan member is responsible f the balance of the treatment cost. F exact benefits and current rates, contact your Della Dental Connect Sales Representative at; (651) 406-5920 (800) 906-5250. DeltaDentalMN.g
Need Assistance? Visit Us Online Contact Us Agent Commission & Contracting: Appointments Questions related to payment Update your ACH infmation Request Fms Delta Dental Individual and Family Plans Plan descriptions Custom broker banner ads and brochures Sales assistance 1-855-648-1409 www.deltadentalmn.g ddmnbroker@deltadentalmn.g 1-866-764-5350 www.thepowerofsmile.com AskUs@ThePowerOfSmile.com Contact Delta Dental Connect f Small Group Sales (5-199 Eligible Employees): Renewals, plan changes plan questions Escalated plan issues Summary plan descriptions 651-406-5920 Toll Free at 1-800-906-5250 www.deltadentalmn.g deltadentalconnect@deltadentalmnadmin.g Delta Dental Large Group Sales: Large individually rated proposals New ASO proposals down to 51 lives enrolled Voluntary fully insured proposals down to 25 lives enrolled Delta Dental Enrollment Department: PLEASE NOTE: Enrollment/ Termination requests, Employee name change other administrative changes MUST BE SUBMITTED IN WRITING Delta Dental Billing & Accounts Receivable Remit Payment to: Delta Dental of NW 5772, PO Box 1450 Minneapolis, MN 55485-5772 1-877-268-3384 David Anderson: danderson@deltadentalmn.g Clive West: cwest@deltadentalmn.g Brenda Metcalf: bmetcalf@deltadentalmn.g Electronic Enrollments: 1-800-928-6459 Paper/Manual Enrollments: 1-800-928-5713 Group Enrollment eenrollment@deltadentalmnadmin.g Fax:1-800-821-5946 Individual & Family Enrollment Individualenroll@deltadentalmnadmin.g 651-406-5984 Toll Free at 1-800-928-6459 651-406-5909 Toll Free at 1-800-906-4702 Individual and Family Billing: billingindividual@deltadentalmnadmin.g Group Billing: billing@deltadentalmnadmin.g Additional Resources: Employee benefits, eligibility & claims status Customer Service 7am - 7pm CT 651-406-5916 Toll Free at 1-800-553-9536 Fax: 651-406-5916 Toll Free at 1-800-553-9536 Eligibility Address Delta Dental of Attn: Enrollment Department PO Box 330 Minneapolis, MN 55440-0330 Claims Address Delta Dental of Attn: Dental Claims PO Box 330 Minneapolis, MN 55440-0330 Cpate Address Delta Dental of 500 Washington Avenue S. Suite 2060 Minneapolis, MN 55415 Fax: 651-406-5978 Toll Free Fax: 1.888.819.6257 DeltaDentalMN.g DDMN.9.17.15.4