Dental Benefits
Delta Dental
The Clovis Unified School District offers two dental plans to its full time and part time employees through Delta Dental of California. Employees may choose the dental plan that best suits their needs. Below is a brief description of the benefit provisions under each plan:
DeltaPremier Plan #6516 - Managed Fee-For-Service Program
Under this program, Delta pays 70% of the approved fees for covered diagnostic, preventive, basic, cast and crown benefits during the first year you are eligible. This percentage will increase 10% each year (to a maximum of 100%) for each enrollee, provided that person visits the dentist at least once during the year. If an enrollee does not use the program during a calendar year, the percentage remains at the level reached the previous year. If an enrollee becomes ineligible for benefits and later regains eligibility, the percentage will drop back to 70%.
| Principal Benefits and Covered Services* |
| WHO’S COVERED |
Primary enrollee and spouse as well as dependent to age 24. |
| DEDUCTIBLES AND BENEFIT MAXIMUM |
$25.00 per person, $75.00 per family, per calendar year (no deductible applies if a DPO dentist is used). The maximum benefit paid per calendar year is $1,500.00 per person |
DIAGNOSTIC AND PREVENTIVE BENEFITS*
oral examinations, cleaning, x-rays, biopsy/tissue examinations, fluoride treatment, space maintainers, specialist consultation |
70% - 100% of Delta dentist’s fee (no deductible applies for these services) |
BASIC BENEFITS**
oral surgery (extractions), fillings, root canals, periodontic (gum) treatment, sealants |
70% - 100% of Delta dentist’s fee |
| CROWNS, JACKETS AND CAST RESTORATIONS** |
70% - 100% of Delta dentist’s fee |
| PROSTHODONTIC BENEFITS** |
50% of Delta dentist’s fee
(subject to maximum allowance) |
| DENTAL ACCIDENT BENEFITS |
100% of Delta dentist’s fee
(separate $1,000 maximum per person per calendar year) |
*Please refer to your Evidence of Coverage for limitations on these benefits. Some examples of limitations on services are the number of cleanings and oral exams covered in a calendar year, and time limitations on filling and crown replacements.
**You must be enrolled in this dental program for 12 continuous months before receiving these benefits.
Under the DeltaPremier program, you may visit any licensed dentist you wish. More than 17,000 dentists in California – 94% of all dentists statewide – are Delta dentists. There are several advantages to choosing a Delta dentist:
| Delta Dentist |
Non-Delta Dentist |
| Claim forms are completed and submitted for you at no charge |
You may have to complete and submit your own claim forms or pay a service fee |
| Your dentist’s fees have been certified by Delta as usual, customary and reasonable – you’re responsible only for the patient share* |
Delta has not certified the dentist’s fees – you are responsible for the difference if your dentist charges more than Delta’s pre-approved fees |
| You may be charged only the Patient Share* at the time of treatment, not Delta’s portion |
You may have to pay the entire bill at the time of treatment and wait for reimbursement |
*Patient Share is the co-payment, any deductible and any amount over the annual maximum. Some services may not be covered; please refer to your Evidence of Coverage. Some examples of services not covered are cosmetic dentistry, experimental procedures and services to correct congenital malformations.
DeltaPreferred Option Plan #6749 - Preferred Provider Program
The DeltaPreferred Option (DPO) is a preferred provider program. The program provides the maximum benefit when you visit a DPO dentist. DPO dentists are Delta dentists that have agreed to charge DPO patients reduced fees.
| PRINCIPAL BENEFITS AND COVERED SERVICES* |
| WHEN TREATMENT IS PROVIDED BY: |
AN IN-NETWORK DENTIST
|
AN OUT-OF-NETWORK DENTIST |
| WHO’S COVERED |
Primary enrollee and spouse as well as dependent children to age 24 |
Primary enrollee and spouse as well as dependent children to age 24 |
| DEDUCTIBLES AND BENEFIT MAXIMUMS |
$0 per person, $0 per family per calendar year. The maximum benefit paid per calendar year is $2,000 per person |
$50 per person, $150 per family per calendar year. The maximum benefit paid per calendar year is $500 per person |
| DIAGNOSTIC AND PREVENTIVE BENEFITS* - oral examinations, cleanings, x-rays, biopsy/tissue examinations, fluoride treatment, space maintainers, specialist consultation |
100% of DPO approved fee (no deductible applies for these services) |
50% of Delta approved fee (no deductible applies for these services) |
| BASIC BENEFITS*
oral surgery (extractions), fillings, root canals, periodontic (gum) treatment, sealants |
100% of DPO approved fee |
50% of Delta approved fee |
| CROWNS, JACKETS AND CAST RESTORATIONS* |
100% of DPO approved fee |
50% of Delta approved fee |
| PROSTHODONTIC BENEFITS*
Bridges, partial dentures, full dentures |
50% of Delta approved fee (subject to a maximum allowance) |
50% of Delta approved fee (subject to a maximum allowance) |
| DENTAL ACCIDENT BENEFITS* |
100% of Delta Dentist’s fee (separate $1,000 maximum per person per calendar year) |
100% of Delta Dentist’s fee (separate $1,000 maximum per person per calendar year) |
*Please refer to your Evidence of Coverage for limitations on these benefits. Some examples of limitations on services are the number of cleanings and oral exams covered in a calendar year, and time limitations on filling and crown replacements.
Delta endodontists, oral surgeons and periodontists are not DPO dentists, but you get in-network benefits when visiting one of these specialists.
Under the DPO program, you may visit any licensed dentist you wish. However, you receive the maximum benefits available under the program when you choose one of the more than 8,600 in-network dental offices throughout California. If you choose an out-of-network dentist, you will benefit by selecting a Delta Dentist.
| IN-NETWORK |
OUT-OF-NETWORK |
|
DPO DENTIST
|
NON-DPO DELTA DENTISTS |
NON-DELTA DENTISTS |
| Your out-of-pocket expense will probably be less because DPO dentists have agreed to charge DPO patients reduced fees |
You will be charged no more than the fees approved by Delta as customary and reasonable |
You will be responsible for the dentist’s fees, which may be higher than those approved by Delta |
| Claim forms will be completed and submitted for you at no charge |
Claim forms will be completed and submitted for you at no charge |
You may have to complete and submit your own claim forms or pay a service fee |
| You may be charged only the patient share* at the time of treatment, not Delta’s portion |
You may be charged only the Patient Share* at the time of treatment, not Delta’s portion |
You may have to pay the entire amount in advance and wait for reimbursement |
*Patient Share is the co-payment, applicable deductible and any amount over the annual maximum. Some services may not be covered; please refer to your Evidence of Coverage. Some examples of services not covered are cosmetic dentistry, experimental procedures and services to correct congenital malformations.
Services that are not covered under the DeltaPremier Plan and the DeltaPreferred Option Plan
Although both programs cover many of the most commonly needed services, some services are not covered. If you are unsure whether a particular procedure is covered, or how much of it is paid for by your program, check with Delta before proceeding.
The following are not covered by the programs:
- Services for injuries or conditions covered under Workers’ Compensation or Employer’s Liability Laws.
- Cosmetic surgery or dentistry or services to correct congenital malformation
- Experimental procedures
- Therapeutic drugs, premedication or pain relievers
- Hospital costs or extra charges for hospital treatment
- Anesthesia (except for general anesthesia for oral surgery)
- Extra-oral grafts, implants, and implant removal
- Treatment related to the temporomandibular joint (TMJ)
- Orthodontic treatment
THE PRECEDING INFORMATION IS NOT INTENDED FOR USE AS A SUMMARY PLAN DESCRIPTION, NOR IS IT DESIGNED TO SERVE AS AN EVIDENCE OF COVERAGE FOR THE PROGRAMS.
BOTH THE DELTAPREMIER PLAN AND THE DELTAPREFERRED OPTION PLAN ARE EASY TO USE
To use your DeltaPremiere plan or your DeltaPreferred Option plan, just call the dental office of your choice and make an appointment. During your first appointment, give your dentist your group number and the primary enrollee’s social security number
Your benefits administrator has a complete list of DeltaPremier and DeltaPreferred Option network dental offices and Delta dentists, or you may call 800.427.3237 to obtain a list of participating dentists in your area. You may also search our online directory via our web site at www.deltadentalca.org.
THE DeltaPremier Program AND THE DeltaPreferred Option Program ARE ADMINISTERED BY DELTA DENTAL PLAN OF CALIFORNIA. IF YOU HAVE SPECIFIC QUESTIONS REGARDING BENEFIT STRUCTURE, LIMITATIONS OR EXCLUSIONS, CONSULT THE EVIDENCE OF COVERAGE OR CONTACT DELTA’S CUSTOMER AND MEMBER SERVICE DEPARTMENT
DELTA DENTAL PLAN OF CALIFORNIA
P.O. BOX 7736
SAN FRANCISCO, CA 94120
For claims, eligibility and benefit inquiries, call Delta’s Customer and Member Service Department toll free at 888.335.8227
THIS IS A BRIEF OUTLINE OF THE PLAN AND IS NOT TO BE ACCEPTED OR CONSTRUED AS A SUBSTITUTE FOR THE PROVISIONS OF THE CONTRACT. |
