delta dental of california summary of benefits and rate...

For groups of 5-49 eligible employees

• No waiting periods for services

• D&P Maximum Waiver® option1 – Enrollees can receive Diagnostic and Preventive (D&P) services without reducing their annual maximum

Small Business Program

Our small business program

offers employers access to a

variety of plan options often

available only to large employers.

These options include preferred

provider organization plans (PPO/

PPO plus Premier) and prepaid

programs featuring copayments

with no annual deductibles.

Summary of Benefits2

Classic ChoiceFor groups of 5–99 eligible employeesOffered exclusively through CoPower.

PPO A

Out-of-network

PPO B-12PPO C

(PPO + Premier)

In-network Out-of-network


In-network

$50 $50 $25 $50

100% 100% 100% 100% 100% 100%

80% 80% 90% 80% 80% 80%

80% 80% 90% 80% 80% 80%

50% 50% 60% 50% 60% 50%

50% Child Only$1,000 lifetime max/patient

Premier

In-network andOut-of-network

$25 individuals, $75 families $25 individuals, $75 families

$1,000 or $1,500 or $2,000 $1,000 or $1,500 or $2,000

100% 100% 50%

Not available Not available

80% 80% 50%

80% 80% 50%

50% 50% 50%

50% Child Only 50% Child Only $1,000 lifetime max/patient $1,000 lifetime max/patient

Optional

$1,000 or $1,500 or $2,000

Calendar Year Deductible(Deductible waived for D&P)

Calendar Year Maximum per Patient (Select one)

Diagnostic & Preventive (D&P) Services•Oral exams (two per calendar year)•Bitewing x-rays •Cleaning (two per calendar year)•One additional cleaning for pregnant

women3

D&P Maximum Waiver

Basic Services & Oral Surgery•Amalgam fillings primary or permanent

teeth•Removal of impacted tooth, soft tissue

Endodontics and Periodontics•Pulpal therapy, root canal therapy•Treatment to the gums and supporting

structures of the teeth

Major Services•Crowns, jackets, cast restorations•Prosthodontic services (dentures and

bridges)•Implants

Orthodontics (optional)

1

PPO A & B-12 — All dentists (in-network and out-of-network) are reimbursed at the lesser of the submitted charge or the PPO provider’s contracted fee.PPO C - PPO plus Premier — Delta Dental PPO dentists are reimbursed at the lesser of the submitted charge or the PPO provider’s contracted fee. Delta Dental Premier® dentists are reimbursed at the lesser of the submitted charge or the Pre-mier provider’s contracted fee. Non-contracted dentists are reimbursed at the lesser of the submitted charge or the fee that satisfies a majority of dentists with the same training and geographical area.

Delta Dental Premier® dentists are reimbursed at the lesser of the submit-ted charge or the Pre mier provider’s contracted fee. Non-contracted dentists are reimbursed at the lesser of the submitted charge or the fee that satisfies a majority of dentists with the same training and geographical area.

1. D&P services will not apply toward the enrollee’s calendar year maximum benefit amount. 2. Subject to Limitations and Exclusions shown on pages 13-14. 3. If the enrollee is pregnant, Delta Dental will pay for the following additional services per calendar year: one additional oral evaluation and either one additional routine cleaning or one additional periodontal scaling and root planing per quadrant.

SMALL BUSInESS PROGRAM

Reimbursement Basis

• No excluded industries

• The calendar year deductible maxes at $75 per family for the Premier/PPO plans

• Statewide rates


Voluntary

PPO Vol

In-network and Out-of-network

PPO

Out-of-network

In-network

$25 individuals, $75 families $25 individuals, $75 families

$1,000 or $1,500 or $2,000 $1,000 or $1,500 or $2,000

100% 100% 50%

Not available Not available

80% 80% 50%

80% 80% 50%

50% 50% 50%

50% Child Only 50% Child Only $1,000 lifetime max/patient $1,000 lifetime max/patient

PPO 1

Out-of-network



In-network

$25/$75 or $50/$150 $25/$75 or $50/$150

100% 100% 100% 80% 100% 100%

90% 80% 80% 80% 80% 80%

90 or 60% 80 or 50% 80 or 50% 80 or 50%

60% 50% 50% 50% 50% 50%

• Employers may contribute up to 74 percent when offering this plan

$50

$1,000

100%

50% Child Only$1,000 lifetime

max/patient


More plan design choices and flexibility:

Options

• Two deductible and three annual maximum levels• Two endo/perio coverage levels• Two ortho lifetime maximum levels• Ortho coverage for Child Only or Adult and Child

PPO 2 PPO 3

None

$40/$120

$25/$75

$50/$150

50%; $1,000 or $1,500 lifetime max/patientChild Only or Adult and Child(ren)

$1,000 or $1,500 or $2,000

Optional

Sealants, Simple Restorations & Extractions

Dental Accidents1

D&P Maximum Waiver®

Endodontics

Periodontics

Oral Surgery

Crowns, Inlays, Onlays, Cast Restorations

Prosthodontics

Orthodontics (Optional)Minimum group size 25 primary enrollees)

80%

100%

50%

50%

50%

50%

50%

Not available

Firs

t tw

elve

mo

nths

Seco

nd t

wel

ve m

ont

hs2

PPO 1,2,3 PPO plus Premier — Delta Dental PPO dentists are re-imbursed at the lesser of the submitted charge or the PPO provider’s contracted fee. Delta Dental Premier dentists are reimbursed at the lesser of the submitted charge or the Premier provider’s contracted fee. Non-contracted dentists are reimbursed at the lesser of the sub-mitted charge or the fee that satisfies the majority of dentists with the same training and geographical area.

2

$50

$1,000

1. Covers conditions caused directly and independent of all other causes, by external, violent and accidental means occurring after the enrollee’s eligibility date. Services must be provided to an enrollee within 180 days following the date of accident. Accidental Benefits are subject to all plan limitations exclusions, deductibles and annual maximums. 2. Covered only following 12-months of continuous enrollment.

All dentists (in-network and out-of-network) are reimbursed at the lesser of the submitted charge or the PPO provider’s contracted fee.

Delta Dental PPO dentists are reim-bursed at the lesser of the submitted charge or the PPO provider’s contracted fee. Delta Dental Premier dentists are reimbursed at the lesser of the submit-ted charge or the Premier provider’s contracted fee. Non-contracted dentists are reimbursed at the lesser of the submitted charge or the fee that satis fies the majority of dentists with the same training and geographical area.

SMALL BUSInESS PROGRAMSMALL BUSInESS PROGRAM

For groups of 5–99 eligible employees

DeltaCare USA is Delta Dental’s prepaid plan that features set copayments, no annual deductibles, and no maximums for covered benefits.

DeltaCare® USA Plans

3

Law firms, associations, groups with seasonal employment, groups without an employee/employer relationship and business with a with high turnover4 are not eligible for any DeltaCare USA plan.

DeltaCare USA

ProcedureCode2 10A 11A 12A 15B Plan 10B3

Calendar Year Deductible per Patient N/A None None None None None

Calendar Year Maximum per Patient N/A None None None None None

Diagnostic & Preventive (D&P) ServicesIntraoral—complete series (including bitewings)

DO210 $0 $0 $0 $0 $0

Basic RestorativeFillings (amalgam filling-one surface)

D2140 $0 $0 $5 $8 $0

PeriodonticsScaling & root planing—four or more teeth per quadrant

D4341 $0 $25 $40 $60 $0

Endodontics

•Root canal—anterior (excluding final restoration)

D3310 $45 $55 $85 $125 $45

•Root canal—molar (excluding final restoration) D3330 $205 $250 $280 $365 $205

Oral Surgery

•Extraction—erupted tooth D7140 $0 $5 $8 $14 $0

•Removal of impacted tooth—completely bony D7240 $70 $90 $95 $120 $70

Restorative

•Crown—full cast high noble metal D2790 $170 $210 $260 $395 $95

•Crown—porcelain fused with high noble metal D2750 $195 $240 $295 $395 $195

Prosthodontics

•Complete denture—maxillary D5110 $100 $145 $215 $365 $100

•Maxillary partial denture—resin base (including any conventional clasps, rests and teeth)

D5211 $80 $120 $180 $325 $80

Orthodontics

•Child—Comprehensive orthodontic treatment of the transitional dentition (child or adolescent to age 19)

D8070 $1,700 $1,700 $1,700 $1,900 $1,700

•Adult—Comprehensive orthodontic treatment of the adult dentition (adults, including covered dependent adult children)

D8090 $1,900 $1,900 $1,900 $2,100 $1,900

Sample Procedures1

1. Subject to the Limitations and Exclusions shown on page 13. See DeltaCare USA Description of Benefits and Copayments available with CoPower for a complete list of procedures covered.2. (2010-2011) Current Dental Terminology codes under copyright by the American Dental Association (ADA). 3. Offered in conjunction with Choice Delta Dental PPO and Premier Plans.4. A business has “high turnover” if 20% or more of the average number of its employees during the past 12 months were newly hired for reasons other than the growth of the business.

•Enrollees select a primary care dentist in the DeltaCare USA network from whom they receive treatment

•Most diagnostic and basic restorative services are covered at little or no cost to the enrollee.

$0, $5, $8, $14, $0

Delta Dental PPO Plans Classic & Options

Delta Dental PPO Plans Voluntary DeltaCare USA

Delta Dental PPO & Premier Plans

Choice

Group Size •Classic: 5–49 employees•Options: 50–99 employees•DE-9C required

•5–99 employees•DE-9C required

•5–99 employees•DE-9C not required

•5–99 employees•DE-9C required

Employer Contribution

•Classic & Options: 75% to 100% of the employee premium Less than 75% of employee

premium

10A, 11A, 12A, 15B:• Option A: 100% for employee

and 100% for dependent premium

•Option B: 75% to 99.9% for employee and 0% to 99.9% for dependents

•Option C: 0% to 74.9% for the employee and 0% for dependents.

•Choice Plan 10B: 100% for employees; minimum of 50% for dependents

100% of the employees premium; 50% of dependent premium

Employer Enrollment Participation Requirements

•All Plans: If the employer contributes 100% of the employee premium all employees must enroll.

•PPO Classic: (groups with 5 to 49 employees):

•Employer contributes 75% to 99.9% of the employee premium.

•80% of all employees must enroll (excluding those with dental coverage elsewhere). Enrollment must not be less than 5 employees for the duration of the contract term.

•PPO Options: (Groups with 50 to 99 employees):

•Employer contributes 75% to 99.9% of the employee premium.

•80% of all employees must enroll (excluding those with dental coverage elsewhere). Enrollment must not be less than 35 employees for the duration of the contract term.

•A minimum of 5 employees must be enrolled.

•If the employer contributes 100% of the employee premium all employees must enroll.

•Employer contribution of 75% to 99.9% a minimum of 5 employees or 80% of all employees, whichever is greater, must enroll.

•Employer contribution of 0% to 74.9% a minimum of 5 employees must enroll. Enrollment must not be less than 5 employees for the duration of the contract term.

100% of all eligible employees; no minimum for dependents

Eligible Employ-ee/dependent Enrollment

100% Employer Paid: All employees must be enrolled following completion of the employer’s eligibility period.•Less than 100% Employer Paid: •Employees are eligible to enroll following the completion of the employer’s eligibility period. Employees not enrolled when eligible may

enroll during the group’s open enrollment (not applicable for Choice) or within 30 days of a qualifying event.•Dependents can be enrolled at the same time as the employee. Dependents not enrolled when eligible can enroll during the group’s

open enrollment or within 30 days of a qualifying event.•Employees who elect dependent coverage must enroll all their eligible dependents.•Children under the age of four may be enrolled during the group’s open enrollment up to or immediately following the child’s 4th

birthday.

Initial Rate Guarantee

•Classic: 12 months•Options: 12 months

24 months, unless waiting period is waived for major benefits; then guarantee is 12 months

•Classic: 12 months•Choice: 6-12 months

•Choice: 6-12 months

Industry Loads See page 7 for a complete list of eligible/ineligible industries

No loads. No ineligible industries.

All industries are eligible except law firms and associations, seasonal employment and businesses with high turnover1.

Industry loads apply-see page 7. No ineligible industries.

Program Guidelines

4

1. A business has “high turnover” if 20% or more of the average number of its employees during the past 12 months were newly hired for reasons other than the growth of the business.

5




Choice

Waiting Period for Services None

There is a 12-month wait on major and orthodontic services.•Thewaitingperiodcan be waived for initial enrollees at takeover with proof of prior coverage in a comprehensive dental plan with no break in coverage.1

•Newhiresand/ordependents are subject to a 12-month waiting period regardless of previous coverage.

None None

Out-of-State No more than 50% of primary enrollees may reside outside of California.

Services must be rendered in the state where the contract is issued.

No more than 50% of primary enrollees may reside outside of California.

Administrative Fees None None

Eligible Dependents

•Legal spouse or domestic partner (if offered by group).•Children to age 26.

•Legal spouse or domestic partner (if offered by group).

•Children to age 26.

Carve-outs

Employee class carve-out is allowed and can consist of management/non-management, union/non-union and hourly/salaried employees. The following will apply:•Delta Dental PPO can be offered to one population and DeltaCare USA can be offered to another

(multiple PPO plans are not allowed).•Carve-out is not allowed with another carrier.•Level 2 rating applies to carve-out groups regardless of industry.•Employer must provide DE-9C identifying the carve-out employees.•Underwriting guidelines apply to each of the carve-out plans.

1099 Employees Not eligible Not eligible

Product Combinations

•Groups cannot offer PPO or DeltaCare USA dual choice with another carrier.

•Employer contribution for employee and dependent coverage must be identical for both plans.

•Classic plans require a minimum enrollment of 10 eligible employees (at least three enrolled in one plan and the balance in the other).

•Options plans require a minimum enrollment of 50 eligible employees (at least 10 enrolled in one plan and the balance in another).

•Requires a minimum enrollment of 5 eligible employees in the PPO plan and 5 in the DeltaCare USA plan.



•Classic plans require a minimum enrollment of 10 eligible employees (at least three enrolled in one plan and the balance in the other).

•Options plans require a minimum enrollment of 50 eligible employees (at least 10 enrolled in one plan and the balance in another).



•Choice plans require a minimum enrollment of 10 eligible employees (at least three enrolled in one plan and the balance in the other).

Retiree Coverage

Dental coverage for retirees is available in conjunction with an active employee plan provided there is no break in coverage and the employer contribution is identical for both active employees and retirees. Coverage must be available to all retirees, not just a select few.

Voluntary See Delta Dental of CA Voluntary PPO column.

Yes.Yes. Classic Plans 10A, 11A, 12A, 15B-Option C only

No

Program Guidelines

1. Submit a copy of the group’s prior PPO plan’s latest bill or the prepaid plan’s evidence of coverage booklet for proof of prior coverage. Prior coverage must include diagnostic and preventive, basic and major services, including specialty care such as endodontics, periodontics and oral surgery.

Not available

6




Choice

Orthodontia

•Classic: An option available to groups with 10+ primary enrollees and only available to dependent children up to age 26.

•Options: An option available to groups with 10+ primary enrollees and available to adults and dependent children up to age 26

•Yes, an option available for groups of 25+ primary enrollees.

•Dependent children up to age 26

•Automatically included for groups of 5+ primary enrollees. Included for adults and children up to age 26.

•An option available to groups with 10+ primary enrollees and only available to dependent children up to age 26.

Existing Delta Dental Groups

Existing Delta Dental and DeltaCare groups are not allowed to transfer into these programs. However, groups will be allowed to enroll into PPO Voluntary plan.

Open

Enrollments

•Classic and Options: Available for groups with employee contributions made on a pre-tax basis.

•Dual choice groups: Employees may change coverage.

•Available for groups with employee contributions made on a pre-tax basis.

•Dual choice groups:•Employees may change

coverage

•Available for groups with employee contributions made on a pre-tax basis.


coverage. •Choice Plan 10B: Dependents

only

•Available for groups with employee contributions made on a pre-tax basis. Applicable for dependent enrollment only


coverage

Waiving Coverage

Coverage can be waived for:•Employees who contribute towards the cost of coverage for themselves and/or their dependents.•Employees and/or dependents with coverage elsewhere.•Not available if the employer pays 100% of the employee and/or dependent premium.

Terminations•Dental coverage will end on the last day of the month when primary enrollee is no longer eligible for coverage.•Dependent coverage will end at the same time as the primary enrollee or when the dependent is no longer eligible.

Case Submission Deadlines Varies by month Varies by month

1. A business has “high turnover” if 20% or more of the average number of its employees during the past 12 months were newly hired for reasons other than the growth of the business.2. Submit a copy of the group’s prior PPO plan’s latest bill or the prepaid plan’s evidence of coverage booklet for proof of prior coverage. Prior coverage must include diagnostic and preventive, basic and major services, including specialty care such as endodontics, periodontics and oral surgery.

Program Guidelines

Delta Dental rates are determined by the employer’s zip code and industry code (see next page). Businesses must be headquartered in California. Voluntary PPO rates are statewide and are not specific to industry.

The following rating regions by Zip Code apply for Delta Dental’s Small Business Program Classic & Options.

Region 1 (Southern California)This region includes zip codes 900-908, 910-928 and 930 The following zip codes are excluded in Region 1 but included in Region 4: 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013, 93014, 93067

Region 2 (northern California)This region includes zip codes 940-941 and 943-951The following zip codes are excluded but included in Region 4: 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999

Region 3 (Central Valley, California)This region includes zip codes 932-933, 935-938, 952-953 and 956-958The following zip codes are excluded but included in Region 4: 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 95646, 95724, 95728

Region 4 (All Other Regions, California)This region includes all excluded zip codes from Region 1, 2, and 3 as well as zip codes beginning 931, 934, 939, 942, 954-955, 959-96.

DELTA DEnTAL RATInG REGIOnS - CLASSIC & OPTIOnS

7

Eligible and Ineligible Industries

8000–8059 8082–8099

Automobile Dealerships 5511-5599 Photographic Studios 7221

Amusement, Recreation, and Entertainment 7800–7999 Restaurants 5800–5899

Tax Return Preparation Services and Miscellaneous Personal Services

Insurance Carriers/Brokers 6300–6499 Real Estate 6500–6799

Religious Organizations (Administration and Management staff only)

Legal 8100–8199 Watch, Clock, and Jewelry Repair 7631

Management Carve-outs 9999

SIC Code(s)

8600–8660;8662–8699

7231–7241

9721

8021, 8071, and 8072

7361–7363

Varies

7389

Classic and Optionsor Level 2 for Choice

Associations and Trusts (except 8661*)

Beauty and Barber Shops

International Affairs

Employment Agencies

Groups with high turnover

Miscellaneous Business Services

Classic and Optionsor Level 2 for Choice

Professional Employer Organizations (PEO)

Private Households

Partnerships

Seasonal Employees (Christmas/Part-time Help)

Seasonal Employees (Agriculture)

Miscellaneous Services not classified elsewhere

Religious Organizations (except churches 8661)

SIC Code(s)

7361

8811

No SIC

No SIC

0761–0783

8999

No SIC

Lev

el 1

Eligible Industries SIC Code(s) Eligible Industries SIC Code(s)

Eligible Industries SIC Code(s) Eligible Industries SIC Code(s)

Advertising (Miscellaneous, not classified) 7319 Medical Groups

Hotels 7000–7099

Jewelry Manufacturing 3911–3915

Dental Offices, Dental Labs, and Medical Labs

Lev

el 2

*Management and administrative staff of Associations and Trusts are eligible under Level 2. Use SIC Code 9999.

8661

7291–7299

Advertising (except Misc., not classified #7319) 7311–7313

Agriculture, Forestry, and Fishing (except seasonal employees) 0100–0999

Hospitals 8062–8069

Independent Auto Repair and Services 7532–7599

7211– 7219/7251

Manufacturing (except Jewelry Manufacturing) 2000–2699

Manufacturing (Chemicals, Allied, and Other) 2810–3999

Mining, Oil, and Gas Extraction 1000 –1499

Miscellaneous Computer Services 7379

Miscellaneous Repair (Welding, etc.) 7692–7699

Museums, Art Galleries, and Gardens 8412-8422

News Syndicates 7383

Photofinishing Labs 7384

Printing and Publishing 2700–2799

9000–9720, 9722–9998

5200–5510, 5610–5699, 5712–5736 5912–5999

Private Schools (Elementary and High School) 8211

Security Systems, Detectives, and Armored Cars 7381–7382

Transportation 4000–4799

Utilities 4900–4999

Wholesale Trade 5000–5199

Retail

Laundry/Garment Services and Shoe Repair Services

Public Administration (Cities, Counties, Police, etc.)

Inel

igib

le S

IC c

od

es

Auto Rental Agencies 7513-7519

Automobile Parking Services 7521

Building Maintenance/Equipment Rental 7349–7359

Collection Agencies and Credit Reporting Services 7322–7323

Communication (Radio, Telephone, TV/Radio, and Broadcasting) 4800–4899

Community Services Organizations/Social Services 8300–8499

Computer Programming and other Computer Services 7371–7379

Construction Contractors 1500–1799

Direct Mailing, Reproduction, and Secretarial Services 7331–7338

Disinfecting and Pest Control Services 7342

Public Education (except Private Schools) 8200–8299

Electrical Repair (Radio, TV, A/C, and Refrigerator) 7622–7629

Engineering and Management Services 8711–8748

Finance (Banks, Securities, and Credit Agencies) 6000–6299

Funeral Services and Crematories 7261

Furniture Repair/Re-upholstery 7641

Government Funded Groups 8300-8499

REGIOn 1* (Generally Southern California)

REGIOn 2*(Generally Northern California)

Plan/CYM** Coverage Tier no OrthoLevel 1

With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2

no OrthoLevel 1

With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2

PPO A 1000 Employee $38.25 $38.25 $45.87 $45.87 $39.32 $39.32 $47.16 $47.16Employee + 1 $75.65 $77.44 $90.80 $92.86 $80.03 $81.91 $96.06 $98.21Employee + 2 or more $117.23 $135.24 $140.71 $162.30 $123.50 $142.32 $148.24 $170.80



PPO B-12 1000 Employee $38.87 $38.87 $46.62 $46.62 $39.96 $39.96 $47.93 $47.93Employee + 1 $76.82 $78.63 $92.20 $94.29 $81.26 $83.17 $97.54 $99.72Employee + 2 or more $118.58 $136.80 $142.33 $164.17 $124.92 $143.96 $149.94 $172.76



PPO C 1000 Employee $48.66 $48.66 $58.35 $58.35 $50.02 $50.02 $59.99 $59.99Employee + 1 $96.22 $97.97 $115.50 $117.52 $101.80 $103.62 $122.19 $124.30Employee + 2 or more $149.13 $166.76 $178.96 $200.09 $157.10 $175.53 $188.53 $210.63



REGIOn 3*(Generally Central Valley, California)

REGIOn 4*(All other regions)


With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2

no OrthoLevel 1

With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2










*Refer to Page 6 for rating region by zip code. **CYM is “Calendar Year Maximum”.

No D&P Waiver

Classic Rates For groups 5-99 eligible employees

8

Remove all the county and zip info from the Classic Plan headers and replace with the following under that region: 1 (Generally Southern California); 2 (Generally northern California); 3 (Gener-ally Central Valley, CA); 4 (All Other Regions). Then make the rates columns narrower so that we can expand the green column.

9

REGIOn 1*(Generally Southern California)

REGIOn 2*(Generally Northern California)


With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2

no OrthoLevel 1

With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2










REGIOn 3*(Generally Central Valley, California)

REGIOn 4*(All other regions)


With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2

no OrthoLevel 1

With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2










*Refer to Page 6 for rating region by zip code. **CYM is “Calendar Year Maximum”.

With D&P Waiver

Classic Rates For groups 5-99 eligible employees

10

Voluntary PPO

Choice

Choice and Voluntary PPO Rates For groups of 5-99 eligible employees

Delta Dental Options For groups of 50-99 eligible employees For mid-size groups, Delta Dental offers their Options portfolio. These plans offer a variety of features and plan design choices so that employers can tailor the product to meet their needs. For rates or a quote, please refer to CoPower’s Delta Dental Options Rate Guide, or contact the LISI sales representative for your area.

no OrthoLevel 1

With OrthoLevel 1

no OrthoLevel 2

With OrthoLevel 2

PPO 1000 Employee $42.59 $42.59 $51.14 $51.14

Employee + 1 $81.48 $83.43 $97.75 $100.12

Employee + 2 or more $134.05 $150.54 $160.84 $180.65

PPO 1500 Employee $51.10 $51.10 $61.30 $61.30

Employee + 1 $90.75 $92.44 $108.85 $110.96

Employee + 2 or more $140.91 $155.46 $169.10 $186.54

PPO 2000 Employee $54.81 $54.81 $65.79 $65.79

Employee + 1 $97.19 $99.02 $116.59 $118.81

Employee + 2 or more $148.81 $164.15 $178.59 $196.98

Premier 1000 Employee $57.06 $57.06 $68.48 $68.48

Employee + 1 $109.41 $111.46 $131.30 $133.74

Employee + 2 or more $180.32 $197.62 $216.36 $237.14


Employee + 1 $123.59 $125.38 $148.31 $150.46

Employee + 2 or more $191.99 $207.22 $230.41 $248.88


Employee + 1 $133.58 $135.56 $160.33 $162.63

Employee + 2 or more $204.28 $220.49 $245.15 $264.80

no Ortho With Ortho

Voluntary PPO 1000 Employee $42.22 $42.22

Employee + Spouse $83.67 $83.67

Employee + Child(ren) $92.16 $111.90

Employee + Family $136.77 $156.50

Plan/CYM* Coverage Tier

Plan/CYM* Coverage Tier

*CYM is “Calendar Year Maximum”.

DeltaCare® USA RatesFor groups 5-99 eligible employees

Participation/Contribution OptionREGIOnS 1 and 2

Los Angeles and Orange counties

REGIOn 3Alameda, Contra Costa, Fresno, Kern, Mariposa,

Riverside, San Bernardino, San Diego, San Francisco,

San Mateo, Santa Clara and Ventura counties.

REGIOn 4Alpine, Amador, Calaveras, Colusa, El Dorado, Imperial, Inyo, Kings, Madera, Marin, Merced, Monterey, Napa, Nevada, Placer, Plumas,

Sacramento, San Joaquin, San Luis Obispo, Santa Bar-

bara, Sierra, Solano, Sonoma, Stanislaus, Tuolumne, Tulare

and Yolo counties.

REGIOn 5Butte, Del Norte, Glenn, Humboldt, Lake, Lassen,

Mendocino, Modoc, Mono, San Benito, Santa Cruz, Shas-ta, Siskiyou, Sutter, Tehama, Trinity and Yuba counties.

Plan 10A

A

Employee $21.14 $24.01 $25.58 $65.89 Employee + 1 $34.87 $39.58 $42.20 $108.70 Employee + 2 or more $51.57 $58.55 $62.40 $160.79

B


C Employee $24.33 $27.23 $28.82 $68.84 Employee + 1 $40.13 $44.94 $47.57 $113.59 Employee + 2 or more $59.35 $66.49 $70.36 $168.00

Plan 11A

A


B


C


Plan 12A

A


B


C


Plan 15B

A


B


C


REGIOnStatewide

Plan 10BChoice

Employee $20.43

Employee + 1 $37.12

Employee + 2 or more $55.11

Employer ContributionEnrollment Guidelines

(minimum of 5 enrolled)

Option A 100% for employee and 100% for dependent premium 100% of all eligible employees and dependents must be enrolled

Option B 75% to 99.9% for employee premium; no minimum for dependents 80% of all eligible employees, not less than 5, dependents voluntary

Option C 0% to 74.9% employee premium; no minimum for dependents Minimum of 5 eligible employee must enroll

Choice Plan 10B 100% for employees; minimum of 50% for dependents 100% of eligible employees

11

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DeltaCare USA Limitations and ExclusionsLimitations1. The frequency of certain benefits is limited. All frequency limitations are

listed in the Description of Benefits and Copayments insert.

2. If the enrollee accepts a treatment plan from the general dentist that includes any combination of more than six crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $100 above the listed copayment for each of these services after the sixth unit has been provided.

3. General anesthesia and/or intravenous sedation/analgesia are limited to treatment by a contracted oral surgeon and in conjunction with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241).

4. Benefits provided by a pediatric dentist are limited to children through age seven following an attempt by the assigned contract dentist to treat the child and upon prior authorization by Delta Dental, less ap-plicable copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis.

5. The cost to an enrollee receiving orthodontic treatment whose cover-age is cancelled or terminated for any reason will be based on the contract orthodontist’s usual fee for the treatment plan. The contract orthodontist will prorate the amount for the number of months remain-ing to complete treatment. The enrollee makes payment directly to the contract orthodontist as arranged.

6. Orthodontic treatment in progress is limited to new DeltaCare USA enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan as long as they continue to be eligible under the DeltaCare USA pro-gram. Active treatment means tooth movement has begun. Enrollees are responsible for all copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.

Exclusions1. Any procedure that is not specifically listed in the Description of Ben-

efits and Copayments insert.

2. Any procedure that in the professional opinion of the contract dentist:

a. has poor prognosis for a successful result and reasonable longev- ity based on the condition of the tooth or teeth and/or surrounding structures;

b. is inconsistent with generally accepted standards for dentistry.

3. Services solely for cosmetic purposes, with the exception of procedure D9972, External bleaching, per arch, or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth abnormalities.

4. Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age.

5. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers and crowns and fixed partial dentures (bridges).

6. Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ).

7. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants and appliances associated therewith) and personalization and characterization of complete and partial dentures.

8. Implant-supported dental appliances and attachments, implant place-ment, maintenance, removal and all other services associated with a dental implant.

9. Consultations for non-covered benefits.

10. Dental services received from any dental facility other than the as-signed contract dentist, a preauthorized dental specialist, or a contract orthodontist except for emergency Services as described in the con-tract and/or Evidence of Coverage (EOC).

11. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility or other similar care facility.

12. Prescription drugs.

13. Dental expenses incurred in connection with any dental or orthodontic procedure started before the enrollee’s eligibility with the DeltaCare USA Program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken and orthodontics unless qualified for the orthodontic treatment in progress provision.

14. Lost, stolen or broken orthodontic appliances.

15. Changes in orthodontic treatment necessitated by accident of any kind.

16. Myofunctional and parafunctional appliances and/or therapies.

17. Composite or ceramic brackets, lingual adaption of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.

18. Treatment or appliances that are provided by a dentist whose practice specializes in prosthodontic services.

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PPO Limitations and ExclusionsLimitations1. We pay for two oral exams, including office visits for observation and

specialist consultations, or combination of these services each calendar year while you are enrolled under any Delta Dental plan.*

2. Full-mouth x-rays and panoramic x-rays when taken individually, are a benefit once in a five year period while you are enrolled under any Delta Dental plan.

3. Bitewing x-rays are provided on request by the dentist, but no more than twice in a calendar year for children to age 18 or once in a calen-dar year for adults age 18 and over, while you enrolled under any Delta Dental plan.

4. Diagnostic casts are a benefit only when made in connection with sub-sequent orthodontic treatment covered under this plan.

5. We pay for two cleanings or a dental procedure that includes a clean-ing each calendar year under any Delta Dental plan.*

Routine cleanings are covered as a Diagnostic and Preventive benefit and periodontal cleanings are covered as a periodontal benefit.

6. Periodontal scaling and root planning are limited to one for each quad-rant each 24-month period.

7. Fluoride treatments are a benefit twice each calendar year under any Delta Dental plan.

8. Sealant benefits include the application of sealants only to permanent first molars through age eight and second molars through age 15 if they are without caries (decay) or restorations on the occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two years of its application.

9. Direct composite (resin) restorations are Benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta Dental’s payment is limited to the cost of the equivalent amalgam restorations.

10. Crowns, Inlays, Onlays and Cast Restorations are Benefits on the same tooth only once every five years, while you are eligible under any Delta Dental plan, unless Delta Dental determines that replacement is required because the restoration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced exten-sive loss or changes to tooth structure or supporting tissues since the replacement of the restoration.

11. Prosthodontic appliances and implants received under any Delta Dental plan will be replaced only after five years have passed, unless Delta Dental determines that there has been such an extensive loss of remaining teeth or change in supporting tissues that the existing fixed bridge, partial or complete denture cannot be made satisfactory.

Delta Dental will replace an implant, a prosthodontic appliance or an implant supported prosthesis you received under another dental plan if we determine it is unsatisfactory and cannot be made satisfactory.

We will pay for the removal of an implant once for each tooth during the enrollee’s lifetime.

12. Delta Dental will pay its percentage of the dentist’s fee for a standard cast chrome or acrylic partial or complete denture. A standard partial or complete denture is one made from accepted materials and by conventional methods.

13. If you select a more expensive plan of treatment than is customarily provided, or specialized techniques, an allowance will be made for the least expensive, professionally acceptable, alternative treatment plan. Delta Dental will pay the applicable percentage of the lesser fee for the customary or standard treatment and you are responsible for the remainder of the dentist’s fee.

For example: a crown where an amalgam filling would restore the tooth; or a precision denture where a standard denture would suffice.

14. Orthodontic services may not be covered by your employer.

a) If orthodontic treatment begins before you become eligible for coverage, Delta Dental’s payments will begin with the first payment due to the dentist following your eligibility date.

b) Delta Dental’s orthodontics payments will stop when the first payment is due to the dentist following either a loss of eligibility, or if treatment is ended for any reason before it is completed.

c) Delta Dental will pay the applicable percentage of the dentist’s fee for a standard orthodontic treatment plan involving surgical and/ or non-surgical procedures. If the enrollee selects specialized orthodontic appliances or procedures chosen for aesthetic consider- ations an allowance will be made for the cost of a standard orthodontic treatment plan and the patient is responsible for the remainder of the dentist’s fee.

d) X-rays and extractions that might be necessary for orthodontic treatment are not covered by orthodontic benefits, but may be covered under diagnostic and preventive or basic benefits.

* If the enrollee is pregnant, Delta Dental will pay for the following ad-ditional services per calendar year: one additional oral evaluation and either one additional routine cleaning or one additional periodontal scaling and root planing per quadrant. Written confirmation of the pregnancy must be provided by the enrollee or the dentist when the claim is submitted.

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PPO Limitations and ExclusionsExclusionsDelta Dental covers a wide variety of dental care expenses, but there are some services for which we do not provide benefits. It is important for you to know what these services are before you visit your dentist.

Delta Dental does not provide benefits for:

1. Services for injuries covered by Workers’ Compensation or Employer’s Liability Laws.

2. Services which are provided to the enrollee by any Federal or State Governmental Agency or are provided without cost to the enrollee by any municipality, county or other political subdivision, except Medi-Cal benefits.

3. Services for cosmetic purposes or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel.

4. Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Examples of such treatment are equilibration and periodontal splinting.

5. Any single procedure, bridge, denture or other prosthodontic service which was started before the enrollee was covered by this plan.

6. Prescribed drugs, or applied therapeutic drugs, premedication or anal-gesia.

7. Experimental procedures.

8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility.

9. Anesthesia, except for general anesthesia and IV sedation given by a dentist for covered oral surgery procedures and select endodontic and periodontic procedures.

10. Grafting tissues from outside the mouth to tissues inside the mouth (“extraoral grafts”).

11. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joints or associated muscles, nerves or tis-sues.

12. Replacement of existing restoration for any purpose other than active tooth decay.

13. Occlusal guards and complete occlusal adjustment.

14. Charges for replacement or repair of an orthodontic appliance paid in part or in full by this plan.

15. Orthodontic services unless Delta Dental’s copayment and maximum amount payable are shown on the highlights page of the Evidence of Coverage.

n CoPower OPTIONS Employer Application.

n List of enrollees, social security numbers, dates of birth, mailing addresses, and dependent information. Use the CoPower OPTIONS Census Enrollment Form–Dental or the CoPower Electronic Census Enrollment.

• Enrolling employees may also complete the CoPower OPTIONS Enrollment/Change Form–Dental. DeltaCare USA enrollees must select a primary care dentist.

n DE-9C quarterly wage statement—reconciled.

n Signed Business Associate Agreement (BAA) from the group.

n Completed waivers and declination of coverage documents.

n A company check for first month’s premium, made payable to CoPower.

note: DeltaCare USA groups must be submitted before the 15th of the month prior to the requested effective date. Groups submitted on a later date may be subject to provider access restrictions.

Enrollment Checklist

For plan administration, contact CoPower at:1600 W. Hillsdale Blvd.San Mateo, CA 94402T: 888.920.2322F: 650.348.1149www.copower.com

For sales, contact LISI at:866.570.LISI (5474)www.lisibroker.com

9/11

Delta Dental of California888.335.8227 | deltadentalins.com

DeltaCare USA800.422.4234 | deltadentalins.com

Carrier Contact Information

CPE-017 11/11

While the information provided in this guide is believed to be accurate as of the print date, it is subject to change without notice. For the most up-to-date information, contact CoPower or your local LISI representative. The benefit information contained in this booklet is summary in nature.

Delta Dental PPOSM

Delta Dental PPO is underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, MS, MT, NV and UT and by not-for-profit dental service companies in these states: CA – Delta Dental of California, PA, MD – Delta Dental of Pennsylvania, NY – Delta Dental of New York, Inc., DE – Delta Dental of Delaware, Inc., WV – Delta Dental of West Virginia. In Texas, Delta Dental Insurance Company provides a Dental Provider Organization (DPO) plan.

Product AdministrationDeltaCare® USA is underwritten in these states by these entities: AL – Alpha Dental of Alabama, Inc.; AZ – Alpha Dental of Arizona, Inc.; CA — Delta Dental of California; AR, CO, IA, ME, MI, NC, NH, OK, OR, RI, SC, SD, VT, WA, WI, WY – Dentegra Insurance Company; VT – Dentegra Insurance Company of New England; AK, CT, DE, FL, GA, KS, LA, MS, MT, TN, WV and Washington, D.C. – Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX – Alpha Dental Programs, Inc.; NV – Alpha Dental of Nevada, Inc.; UT – Alpha Dental of Utah, Inc.; NM – Alpha Dental of New Mexico, Inc.; NY – Delta Dental of New York, Inc.; PA – Delta Dental of Pennsylvania; VA – Delta Dental of Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products.

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