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Health Fund

Looking At Eligible And Ineligible Expenses

The DeltaCare USA DHMO covers a wide range of services, including but not limited to those described below. To find out whether a particular service not listed below is covered, please refer to your DeltaCare EOC Booklet or contact Delta Dental's Customer Service Department. The DeltaCare EOC Booklet can also be found on our website.

Eligible Expenses

The following is a list of most, but not all, covered services that you can receive at no cost or for a minimal copaymentA fixed dollar amount you pay for an eligible expense at the time the service is provided.:

Diagnostic and Preventive Benefits

These benefits include:

  • Comprehensive oral evaluation;
  • Comprehensive periodontal evaluation;
  • Intraoral radiographs - complete series (including bitewings);
  • Limited oral evaluation - problem-focused;
  • Periodic oral evaluation;
  • Prophylaxis (cleaning) - adult or child: 1 per 6-month period;
  • Sealant, per tooth - limited to permanent molars through age 15;
  • Space maintainer - fixed - unilateral;
  • Space maintainer - fixed - bilateral; and
  • Space maintainer – removable – unilateral;
  • Space maintainer – removable – bilateral; and
  • Topical application of fluoride, including prophylaxis (up to age 19) - 1 per 6-month period.
Restorative Benefits

Restorative benefits include:

  • Amalgam - four or more surfaces, permanent;
  • Amalgam - four or more surfaces, primary;
  • Resin-based Composite crown, anterior – primary;
  • Resin-based composite – four or more surfaces or involving incisal angle (anterior);
  • Resin based composite – four or more surfaces - posterior;
  • Inlay – metallic/porcelain/ceramic/resin-based composite – three or more surfaces; and
  • Onlay – metallic/porcelain/ceramic/resin-based composite – four or more surfaces.
Oral and Maxillofacial Surgery Benefits

Oral surgery benefits include preoperative and postoperative evaluations and treatment under local anesthetic, as well as:

  • Removal of impacted tooth - soft tissue/partially bony/completely bony;
  • Root removal - exposed roots;
  • Single tooth extraction/each additional;
  • Surgical removal of erupted tooth;
  • Surgical removal of residual tooth roots;
  • Biopsy of oral tissue – soft (does not include pathology laboratory procedures);
  • Removal of lateral exostosis (maxilla or mandible); and
  • Frenulectomy (also known as frenectomy or frenotomy).
Peridontic Benefits

Periodontic benefits include preoperative and postoperative evaluations and treatment under a local anesthetic, as well as:

  • Gingivectomy or gingivoplasty, - four or more contiguous teeth or tooth bounded spaces per quadrant;
  • Osseous surgery (including flap entry and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant; and
  • Periodontal scaling and root planing – four or more teeth per quadrant (limited 4 quadrants during any 12 consecutive months).
Prosthetic Benefits (Crowns, Bridges and Dentures)

Prosthetic benefits include:

  • Crown - porcelain/ceramic*;
  • Crown - resin (laboratory);
  • Denture - complete maxillary or mandibular (upper or lower);
  • Inlay - three or more surfaces - base noble metal; and
  • Onlay - four or more surfaces - base noble metal.
Endodontic Benefits

These benefits include:

  • Pulp capping (direct/indirect);
  • Root canal therapy - anterior (excluding final restoration);
  • Root canal therapy - bicuspid (excluding final restoration);
  • Root canal therapy - molar (excluding final restoration);
  • Apicoectomy/periadicular surgery - anterior;
  • Apicoectomy/periadicular surgery - bicupsid (first root);
  • Apicoectomy/periadicular surgery - molar (first root); and
  • Therapeutic pulpotomy (excluding final restoration).
General Services

These benefits include:

  • Local anesthesia; and
  • Palliative (emergency) treatment of dental pain.
Orthodontic Benefits

Orthodontic benefits are provided for:

Subject to the limitations noted below, start-up fees (excluding records) which include initial examination, diagnosis, consultation and initial banding, are also covered.

Note: Porcelain on molars is considered optional treatment. Base noble metal is the benefit. High noble metal (precious), if used, will be charged to the patient at the additional laboratory cost of the high noble metal. This applies to crowns, bridges, cast and post cores, inlays and onlays.

Dental Plan Limitations

For specific benefit limitations please refer to your DeltaCare EOC booklet (which can be found on our website) or contact Delta Dental's Customer Service Department. Generally speaking, the following dental benefits are subject to the following limitations:

  • Bitewing X-rays are limited to not more than one series of four films in any six-month period.
  • The replacement of an existing inlay, onlay, crown, fixed partial denture (bridge) or a removable full or partial denture is covered when:
    • The existing restoration/bridge/denture is no longer functional and cannot be made functional by repair or adjustment, and
    • Either of the following:
      The existing non-functional restoration/bridge/denture was placed five or more years prior to its replacement, or

      If an existing partial denture is less than five years old, but must be replaced by a new partial denture due to the loss of natural tooth, which cannot be replaced by adding another tooth to the existing partial denture.
  • Denture relines are limited to one per denture during any 12 consecutive months.
  • Full-mouth debridement (gross scale) is limited to one treatment during any 12 consecutive months;.
  • Full-mouth X-rays are limited to one set every 24 consecutive months.
  • Periodontal treatments (root planing/subgingival curettage) are limited to four quadrants during any 12 consecutive months.
  • Prophylaxis treatment is covered once every six months (includes periodontal maintenance following active therapy).
  • Sealant benefits include the application of sealants only to permanent first and second molars with no decay, with no restorations and with the occlusal surface intact, for first molars up to age 9 and second molars up to age 14. Sealant benefits do not include the repair or replacement of a sealant on any tooth within three years of its application.

The DHMO provides coverage for orthodontic treatment plans when you see a DeltaCare network orthodontist. Your orthodontic benefits are subject to the following limitations:

  • Orthodontic treatment must be provided by a DeltaCare orthodontist.
  • The DHMO covers 24 months of orthodontic treatment.
  • Should your coverage be canceled or terminated for any reason, and at the time of cancellation or termination you are receiving orthodontic treatment, you (and not DeltaCare) will be responsible for paying the balance due for treatment provided after cancellation or termination. In such a case, your payment will be based on a maximum of $2,300 for dependent children up to age 19 and $2,500 for the participant and all covered dependents over the age of 19. The amount will be prorated over the number of months to completion of the treatment and will be payable on such terms and conditions as are arranged between you and the orthodontist. Start-up fees are included in these amounts.
  • Start-up fees cover the initial examination, diagnosis, consultation and retention phase of treatment of up to two years. This includes initial construction, placement of retainers and adjustments to them, as well as office visits for a maximum period of two years.
Ineligible Expenses

Although the DHMO covers a wide range of dental services, some services are not covered. It is important for you to know what these services are before you visit your dentistA doctor of dentistry who is licensed to practice dentistry at the time and place involved where the particular dental procedure was rendered.. To find out if a specific benefit is ineligible under your plan, please refer to your DeltaCare EOC booklet, issued by DeltaCare USA (the EOC can also be found on our website).

The DHMO does not cover the following services:

  1. Accidental injuryBodily harm caused by an accident. The injury must also result, for the purposes of accidental death and dismemberment coverage, directly and independently of all other causes, in a loss covered by the plan., which is defined as damage to the hard and soft tissues of the oral cavity resulting from forces external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal masticatory (i.e., chewing) function will be covered at the normal schedule of benefits;
  2. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments;
  3. Any procedure that in the professional opinion of the Contract Dentist:
    • has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or
    • is inconsistent with Generally Accepted Standards of Dentistry;
  4. Congenital malformations (e.g., congenitally missing or supernumerary teeth), enamel and dentinal dysplasias, etc.); except for the treatment of newborn children with congenital defects or birth abnormalities;
  5. Restoration placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformation of teeth;
  6. Crown lengthening procedures;
  7. Cysts and malignancies;
  8. Dental conditions arising out of and due to your employment, or for which Workers' Compensation is payable;
  9. Dental expenses incurred in connection with any dental procedures started after eligibility for coverage has terminated;
  10. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility;
  11. Dental services received from any dental office other than the assigned DeltaCare office, unless expressly authorized in writing by DeltaCare or as cited under "Emergency Services" on page 5 of the EOC Booklet;
  12. Dispensing of drugs not normally supplied in a dental facility;
  13. General anesthesia and the services of a special anesthesiologist;
  14. Implant placement or removal, and appliances placed on or services associated with implants, including, but not limited to, prophylaxis and periodontal treatment;
  15. Loss or theft of fixed and removable prosthetics (e.g., crowns, bridges, full or partial dentures);
  16. Prophylactic removal of impactions (asymptomatic/nonpathological); extraction of teeth when teeth are asymptomatic/non-pathologic (no signs or symptoms of pathology or infection), including, but not limited to, the removal of third molars and orthodontic extractions;
  17. Services that are provided by a State government agency or are provided without cost by any municipality, county or other subdivision, except as provided in Section 1373(a) of the California Health and Safety Code;
  18. Consultations for non-covered benefits;
  19. Treatment of fractures and dislocations; and
  20. Treatment required by reason of war.

  21. The following orthodontic services also are not covered:

  22. Lost, stolen or broken orthodontic appliances, functional appliances, headgear, retainers and expansion appliances;
  23. Pre-treatment, mid-treatment and post-treatment records, including cephalometric X-rays, tracings, photographs and study models;
  24. Retreatment of orthodontic cases;
  25. Treatment in progress when eligibility for coverage begins;
  26. Transfer after banding has been initiated.
  27. Changes in treatment necessitated by accident of any kind;
  28. Initial or continuing orthodontic treatment when such treatment would be inconsistent with Generally Accepted Professional Standards;
  29. Surgical procedures incidental to orthodontic treatment;
  30. Myofunctional therapy;
  31. Surgical procedures related to cleft palate micrognathia or macrognathia;
  32. Treatment related to temporomandibular joint disturbances;
  33. Supplemental appliances not routinely used in typical comprehensive orthodontics;
  34. Restorative work caused by orthodontic treatment;
  35. Phase I orthodontics, as well as activator appliances and minor treatment for tooth guidance and/or arch expansion. Phase I orthodontics is defined as early treatment, including interceptive orthodontia, prior to the development of late mixed dentition;
  36. Extractions solely for the purpose of orthodontics;
  37. Treatment in progress at inception of eligibility, unless qualified for the orthodontic treatment in progress provision; and
  38. Composite bands, lingual adaption of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.

In addition, treatment that extends more than 24 months from the point of banding dentition will be subject to an office visit charge at the orthodontist's reasonable and customary fee.