The DeltaCare USA plan provides dental services at little or no cost to you when you go to a network provider. Members select a Primary Care Dentist (PCD) who coordinates all of their care. There are no deductibles to pay under this plan, and no claim forms to fill out. For covered services, you pay a portion of the cost according to a copay schedule, which is available from the Belkin People Department or on The HUB.
The dental PPO gives you the option to go to any licensed provider. If you go to a dentist in the PPO network, this dentist will charge discounted fees. This means that you will pay the lowest out-of-pocket costs, and you won’t have to fill out any claim forms.
If there are no Delta Dental PPO network dentists available, you can choose out-of-network providers from the Delta Dental Premier network. Delta Premier dentists also have negotiated fees, but discounts are not as much as with Delta PPO dentists.
If you decide to see an out-of-network non-Delta Dental provider, the plan will reimburse you based on Delta Dental’s program allowance for a particular dental service in your area. If your out-of-network dentist charges more than the program allowance covered by the plan, you will pay the difference. You will pay the full cost of services and complete a claim form for reimbursement.
In addition, the plan covers three cleanings per year at no charge if you see a preferred provider.
| Dental | DeltaCare DHMO (CA Only) | Delta Dental PPO* | ||
|---|---|---|---|---|
| Benefits and Covered Services** | DeltaCare USA Network | Preferred | Premier | Out-of-Network |
| Calendar Year Deductible | None |
$25/individual
$75/family
|
$50/individual
$150/family
|
$50/individual
$150/family
|
| Maximum Benefit | None | $1,250/person/calendar year | ||
| Preventive Services | No charge (copays may apply for some services) | No charge*** | 20% of negotiated fee | 20% of program allowance + balance |
| Basic | Copays apply depending on service | 20% of negotiated fee | 20% of negotiated fee | 20% of program allowance + balance |
| Major | Copays apply | 50% of negotiated fee | 50% of negotiated fee | 50% of program allowance + balance |
| Orthodontia | Copays apply | 50% (lifetime maximum benefit of $1,500 per person) | ||
*Reimbursement is based on PPO contracted fees for in-network Delta Dental PPO dentists and program allowance for Delta Dental Premier and out-of-network dentists.
**Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.
***Members are eligible for up to 3 preventive teeth cleanings (prophylaxis) per calendar year.