Dental

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DeltaCare DHMO Plan

24 Payroll Deductions – Per Pay Period Cost
Employee Only: $7.04
Employee + 1 Dependent: $13.06
Employee + 2 or more Dependents: $19.08

In-Network Benefits

The DHMO dental plan is an in-network only plan that requires all services be received by a Primary Dental Provider (PDP). Employees and their dependents must select a participating dentist in the DeltaCare USA network to receive covered services. There is no coverage for services received out-of-network.

Out-Of-Network Benefits

The DHMO plan does not cover any services rendered by out-of-network facilities or providers.

Delta Dental PPO Low and High Plans

Delta Dental Low PPO Plan

24 Payroll Deductions – Per Pay Period Cost
Employee Only: $15.70
Employee + 1 Dependent: $31.19
Employee + 2 or more Dependents: $45.86

Delta Dental High PPO Plan

24 Payroll Deductions – Per Pay Period Cost
Employee Only: $19.86
Employee + 1 Dependent: $39.46 
Employee + 2 or more Dependents: $58.02

In-Network Benefits

The PPO plan provides benefits for services received from in-network and out-of-network providers. It is also an open access plan which allows for services to be received from any dental provider without having to select a Primary Dental Provider (PDP) or obtain a referral to a specialist. The network of participating dental providers the plan utilizes is the Dental PPO Network. These participating dental providers have contractually agreed to accept Delta Dental’s contracted fee or “allowed amount”. This fee is the maximum amount a Delta dental provider can charge a member for a services. The member is responsible for a Plan Year Deductible (PYD) and then coinsurance based on the plan’s charge limitations.

Out-Of Network Benefits

Out-of-Network Benefits are used when members receive services by a non-participating Delta Dental provider. Delta Dental reimburses out-of- network services based on what it determines is the Maximum Reimbursable Charge (MRC). The MRC is defined as the most common charge for a particulate dental procedure performed in a specific geographic area. If services are received from an out-of-network dentist, the member will pay the out-of-network benefit plus the difference between the amount that Delta Dental reimburses (MRC) for such services and the amount charged by the dentist. This is known as balance billing. Balance billing is in addition to any applicable plan deductible or coinsurance responsibility.

Please Note:

If a member is not able to use a Delta Dental PPO provider, then services can be received from a Delta Dental Premier Provider. Delta Dental Premier Providers are considered out-of-network dentists. These dentists have agree to accept Delta Dental’s Maximum Plan Allowance (MPA) for each single procedure however, the provider may still bill for the difference of the MPA and the Premier Dental Agreement amount. The member is responsible for verifying whether the treating dentist is a PPO Dentist or Premier Dentist.