|
||||||||
| Â | PREVENTATIVE |
PPO 1000 |
PPO 1500 |
|||||
| Plan Availability | All 50 States | All 50 States | All 50 States | |||||
| Enrollment Deadline | 18th of month Prior to Effective date | 18th of month Prior to Effective date | 18th of month Prior to Effective date | |||||
| Provider Lookup | Search Providers | Search Providers | Search Providers | |||||
| Annual Maximum | $1,000 (per person) | $1,000 (per person) | $1,500 (per person) | |||||
| Annual Deductible | Per Person: None | In-Network: Out-of-Network: | In-Network: Out-of-Network: | |||||
| Preventive & Diagnostic Exams; Cleanings; Bitewing X-Rays; Full Mouth X-Rays; Fluoride Treatments (Frequency limitations apply); Space Maintainers |
In-Network: Covered at 100% Out-of-Network: Covered at 100% | In-Network: Covered at 100% Out-of-Network: Covered at 80% | In-Network: Covered at 100% Out-of-Network: Covered at 80% | |||||
| Basic Fillings; Simple Extractions; Oral Surgery; Periodontics; Root Canals (Endodontics); Sealants |
N/A | In-Network: Covered at 80% Out-of-Network: Covered at 50% | In-Network: Covered at 80% Out-of-Network: Covered at 50% | |||||
| Major Crowns & Gold Restorations; Bridgework; Full & Partial Dentures; Repair of Dentures; Implants |
N/A | In-Network: Covered at 50% Out-of-Network: Covered at 50% | In-Network: Covered at 50% Out-of-Network: Covered at 50% | |||||
| Carryover Max | This valuable benefit feature allows you to carry over a portion of your unused standard annual maximum benefit limit into the next year, and beyond. You can accumulate part of your unused benefit dollars from a healthy year and use it for larger, more expensive procedures in the future†such as bridges, crowns, and root canals. | This valuable benefit feature allows you to carry over a portion of your unused standard annual maximum benefit limit into the next year, and beyond. You can accumulate part of your unused benefit dollars from a healthy year and use it for larger, more expensive procedures in the future†such as bridges, crowns, and root canals. | This valuable benefit feature allows you to carry over a portion of your unused standard annual maximum benefit limit into the next year, and beyond. You can accumulate part of your unused benefit dollars from a healthy year and use it for larger, more expensive procedures in the future†such as bridges, crowns, and root canals. | |||||
| Â | ||||||||
| Â | ||||||||
• To be eligible for coverage, a service must be required for the prevention, diagnosis, or treatment of a dental disease, injury, or condition. Services not dentally necessary are not covered benefits. Your dental plan is designed to assist you in maintaining dental health.The fact that a procedure is prescribed by your Dentist does not make it dentally necessary or eligible under this program. We can request proof(such as x-rays, pathologyreports, orstudy models)to determine whetherservices are necessary. Failure to provide this proofmaycause adjustment or denial of any procedure performed.
• Services for injuries or conditions which are compensable under Workers Compensation Employers Liability Laws; services provided to the eligible patient by any Federal or State Government Agency or provided without cost to the eligible patient by any municipality, county, or other political subdivision.
• Services with respect to congenital or developmental malformations (including TMJ and replacing congenitally missing teeth), cosmetic surgery, and dentistry for purely cosmetic reasons (e.g., bleaching, veneers, or crowns to improve appearance).
• Services provided in orderto alter occlusion (change the bite);replace tooth structure lost by wear, abrasion, attrition, abfraction, or erosion;splint teeth; ortreat or diagnose jawjoint and muscle problems (TMJ).
• Specialized or personalized services (e.g., overdentures and root canals associated with overdentures, gold foils) are excluded and a benefit will be allowed for a conventional procedure (e.g., benefiting a conventional denture towardsthe cost of an overdenture and the root canals associated with it. The patient is responsible for additional costs.)
• Prescribed drugs, analgesics(pain relievers), fluoride gel rinses, and preparations for home use.
• Procedures to achieve minor tooth movement.
• Experimental procedures, materials, and techniques and procedures not meeting generally accepted standards of care.
• Educational services such as nutritional or tobacco counseling for the control and prevention of oral disease. Oral hygiene instruction or any equipment or supplies required.
• Any service that has not been performed by a person duly licensed as an oral surgeon or as a Dentist in the state in which the treatment was rendered or by their auxiliary personnel who are duly licensed to perform the services at their direction.
• Charges for hospitalization including hospital visits or broken appointments, office visits, and house calls.
• Services performed prior to effective date or after termination of coverage. Benefits are payable based on the Completion Date oftreatment.
• Services performed for diagnosis such as laboratory tests, caries tests, bacterial studies, diagnostic casts, or photographs
• Temporary procedures and appliances, pulp caps, occlusal adjustments, inhalation of nitrous oxide, analgesia, local anesthetic, and behavior management.
• A subset of a more comprehensive service or procedures or preparations which are part of or included in the final restoration (bases, acid etch, or micro abrasion).
• Transplants.
• Periodontal charting, chemical irrigation, delivery of local chemotherapeutic substances, application of desensitizing medicine,synthetic bone grafts, and guided tissue regeneration.
• Post removal (not in conjunction with root canal therapy).
• Completion of Claim Forms, providing documentation, requests for pre-determination, and services submitted for payment more than twelve (12) months following completion.
• Separate fee for infection control and OSHA compliance.
• Maxillofacial surgery and prosthetic appliances.
• Expenses for replacement of a lost, missing or stolen prosthetic device or other duplicate appliance.
• Expenses for services or supplies for which no charge is made that the Covered Person is legally obligated to pay or for which no charge would be made in the absence of dental expense coverage.
• Expenses for myofunctional therapy.
• Expenses for appliances or restorations necessary to alter vertical dimension or to restore occlusion. • Expenses for services or supplies for accidental injury.
• Expenses which are incurred in connection with any injury or disease arising out of the ownership, maintenance or use of a motor vehicle, except as required by NJAC11:3- 37.3. For expenses incurred in connection with any injury or disease arising out of the ownership, maintenance, or use of a motor vehicle, this Contract shall be secondary.
• Duplicative Dental Services performed on the same day.
• Delta Dental will not coordinate benefits unless the other plan provides benefits for dental services.
• Specialized techniques including but not limited to swing locks, dolder bars, special staining, halder bars, connector bars, metal bases, cone beam capture imaging interpretation and manipulation, ridge augmentation and/or preservation.
• Dental Services submitted for payment as part of a Claim which has knowingly inaccurate information pertinent to the Claim (such as the Dental Service actually rendered, the date of service, the existence of other coverage, or the fee for the Dental Service).
• Tooth preparation; acid etching; temporary restorations and crowns; bases; direct and indirect pulp caps; polishing; caries removal; microabrasion; endodontic working, final treatment, and follow up radiographs; occlusal adjustments; post removal; gingivectomy In Conjunction With restorations; impressions; lab fees and material; local anesthesia services in conjunction with operative or surgical procedures, and other Dental Services which Delta Dental considers to be part of a more Comprehensive Dental Service.Â
Dental Services for which the Dentist does not normally charge.
• Sales taxes on Dental Services.
• All other services not specifically included in this Contract.Â
This is a general description of your dental plan to be used as a convenient reference, and some exclusions and limitations may not be listed.
All benefits are governed by the Master Group Contract.
If You Have Coverage Through Another Plan-Coordination of Benefits (COB) Generally, if you are covered by more than one group dental plan and in some cases a group medical plan, your expenses will be shared between the plans, up to the full amount of the allowable charges. This includes dual Delta Dental coverage, as well as coverage by Delta Dental and another group plan. Make sure you inform your Dentist that you are covered by more than one plan. If you are covered by more than one dental benefit plan, you or your Dentist should file all your claims with each plan and provide each plan with information regarding the other plans under which you are covered. If you are covered by more than one Delta Dental of New Jersey plan, you or your Dentist just need to submit the claim once, and we will coordinate your benefits. If you are covered by Delta Dental and another group plan, you or your Dentist need to submit the claim to the primary group plan. Afte rthe primary group plan has issued a statement of benefits, you or your Dentist should send that statement of benefits to the second group plan along with a Claim Form.
This plan coordinates benefits according to the Birthday Rule.
By coordinating benefits, we avoid duplication of payment for the same services, managing
your benefit dollars for future procedures and ensuring your group that we are effectively
administering your benefits.Â
