Plan Benefits. Forgot Is general anesthesia/intravenous sedation covered? This option provides excellent coverage with predictable copayments. 2019 Summary of Benefits (SOB) DeltaCare USA DHMO. endstream endobj startxref (In most states, if they do not select a primary care dentist, Delta Dental will assign one near the enrollee’s home address.). The primary care dentist coordinates specialty care needs for oral surgery, pediatric dentistry, endodontics or periodontics with a DeltaCare USA network specialist. You may request electronically a list of your benefits by submitting the online Customer Service Request for DeltaCare USA. DELTACARE USA Managed care option—all dental care must be coordinated through your network dentist DELTA DENTAL PPO To receive the highest level of benefits, use Delta Dental PPO dentists NATIONWIDE NONE KNOW YOUR OPTIONS BEFORE YOU CHOOSE GLOSSARY — Here’s a key to the abbreviations you’ll see throughout this summary chart. flyer1.3 MB for more help on finding a network dentist. Please refer to Schedule B for further clarification of Benefits. DeltaCare USA is a closed network product* that features set copayments, no annual deductibles and no maximums for covered benefits. See the "Limitations and Exclusions of Benefits." Enrollees should discuss all treatment options with … Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis. Treatment for pre-existing conditions, such as extracted teeth, is covered under the DeltaCare USA program. When you enroll, you select a contract dentist to provide services. Offered through Delta Dental Insurance Company, the DeltaCare USA program is designed to encourage you and your family to visit the dentist regularly to maintain your dental health. You may request electronically a list of your benefits by submitting the online Customer Service Request for DeltaCare USA. Manage your enrollment and view eligibility and benefits. If there is no network specialist within the service area, a referral to an out-of-network specialist will be authorized at no extra cost, other than applicable copayments. In Florida, Delta Dental Insurance Company provides DeltaCare USA Plan benefits as a Prepaid Limited Health Service Organization as described in Chapter 636 of the Florida Statutes. Primary care dentists may be able to help find an orthodontist within the DeltaCare USA network. SCHEDULE C INFORMATION CONCERNING BENEFITS UNDER THE DELTACARE USA PLAN [Group Name] Dental Plan Combined Evidence of Coverage and Disclosure Plan PGE-CA-dc-19 1 INTRODUCTION We are pleased to welcome you to the DeltaCare USA dental plan . Refer to your benefit plan to determine whether preventive services are covered for you. How do enrollees select or change their general dentist? Created with Sketch. Share this Responsible Office(s) Employee Benefits. Created with Sketch. Copays do not apply to services received from participating specialty dentists. Welcome to DeltaCare DeltaCare is an innovative dental plan that provides you with comprehensive care at a significantly lower cost than most other dental plans—which means great value for you. H0524_19SB003_M PBP 003 60872209 S 003 January 1–December 31, 2019 . DeltaCare USA is Delta Dental’s dental HMO, which offers low-cost dental coverage with a focus on preventive care. Yes, your DeltaCare USA plan provides coverage for accidental injury (caused by external forces) at 100% of the contract dentist’s “filed fees” for benefits (less any applicable copayments). Enrollees must be eligible under their DeltaCare USA plan when the accident occurs. Dentist changes made by the 21st of the month will take effect on the first of the following month. At the time of service, enrollees pay the dentist only the listed copayment (found in their plan booklet) for covered services. DeltaCare USA is a dental program that provides you and your family with quality dental benefits at an affordable cost. INFORMATION CONCERNING BENEFITS UNDER THE DELTACARE USA PROGRAM THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. For a complete description of the details of your coverage, please refer to your coverage documents. DeltaCare USA (administered by Delta Dental Insurance Company) provides you and your family with quality dental benefits at an affordable cost. You can see any dentist you want, but will pay less if you go to a dentist in one of the two Delta Dental networks: • Delta Dental PPO • Dental Premier Dentists of both the Delta Premier and Delta Dental PPO are in … Read more + less - DeltaCare USA is a dental program that provides you and your family with quality dental benefits at an affordable cost. A prepaid plan requires you and your eligible dependents to use a dentist from a specific list of dentists who are located in California and who contract with your selected prepaid carrier. UT … DeltaCare® USA Dental benefits the easy way Underwriter Delta Dental of California 17871 Park Plaza Drive, Suite 200 Cerritos, CA 90703 Claims and Correspondence P.O. * Your benefits may differ from the general information provided here. The plan is unique in its emphasis on preventive services, which are fully covered. With our Online Services, it’s simple for your DeltaCare USA enrollees to maximize their plan. Forgot Refer to your benefit plan to determine whether these requirements apply to you. However, benefits are not provided for any dental treatment-in-progress started before joining the program (such as teeth prepared for crowns, root canals and impressions for dentures). DeltaCare USA, Premier Access, SafeGuard, and Western Dental The prepaid plans require you and your eligible dependents to use a dentist from a specific list of dentists who are located in California and who contract with your selected prepaid carrier. Box 1810 Alpharetta, GA 30023. If you or an eligible member of your family has Once redeemed, Choice Benefits cannot be exchanged or replaced. Will result in additional fees SafeGuard, and Western dental benefits made easy … H0524_19SB003_M PBP 60872209... 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