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Health Fund

Paying For Your Care

Whether you see a Delta dentistA doctor of dentistry who is licensed to practice dentistry at the time and place involved where the particular dental procedure was rendered. or a non-Delta dentist, the Dental Plan covers the same broad range of dental services, including emergency dental care. However, the amount you pay for each service depends on the type of provider you see.


Before the Dental Plan begins to pay benefits, you must meet either an individual or a family calendar-year Dental Plan deductible for most services. In addition, there's a separate lifetime deductibleThe amount you must pay for covered services in a plan year before the plan begins to pay benefits. for orthodontia treatment.

There is no deductible for diagnostic and preventive care. That means you can receive diagnostic and preventive care services without first meeting your deductible.

There is a maximum family deductible for each plan year. Once two covered family members meet their individual deductibles, the family maximum has been met. That means that no other covered family member is required to meet his/her individual deductible for that plan year before benefits are paid.


Once you meet the deductible, the Dental Plan pays a percentage of the dental service, and you pay the rest. This is called coinsuranceThe percentage of eligible expenses you're responsible for paying.. You are responsible for a higher coinsurance when you see a non-Delta dentist.

Coordination of Benefits

For the general COB rules, see page 51. The Dental Plan will allow up to the negotiated rate of the primary carrier, not the total billed amount. The COB processing will review the charges on the primary EOB. If the EOB demonstrates that a service is not covered under the primary carrier, but is a covered benefit under the Fund's Dental Plan, the charge will be allowed showing a zero dollar payment from the primary plan and will use the total billed charge as the eligible amount. There is no coordination between two dental HMO plans. There can be coordination between a Dental HMO and a PPO plan in the following scenario:

If your primary dental coverage is an HMO and your secondary coverage is PPO, the dentist can bill out your copayments from your dental HMO to the PPO plan. However, if your primary coverage is a PPO plan and your secondary coverage is a HMO plan, there will be no coordination of benefits.

Reasonable And Customary (R&C) Limits

R&C limits are maximums for charges considered reasonable and customary based on what 80% of providers in your geographic area charge for similar services or supplies. (A "geographic area" is an area grouped by several ZIP Codes.)

R&C limits apply only when you see a non-Delta dentist. The plan doesn't cover charges above R&C limits - they are your responsibility. To find out whether your non-network dentist's charges fall within R&C limits for a specific service before you receive care, ask your dentist to submit a predetermination of benefitsThe process of obtaining certification or authorization from a plan for a procedure before it's performed. to Delta Dental which describes the anticipated service and charges. Delta Dental will provide a written response stating what it will pay for the service. (See "Predetermination of Benefits".)

Annual Benefit Maximum

The annual benefit maximum represents the total amount the Dental Plan will pay for each family member in a calendar year before you must begin paying 100% of the cost of your dental care.

Orthodontic treatment for children up to age 19 is subject to a separate calendar-year maximum and a lifetime maximum benefit for each covered person. In addition, the maximum paid by Delta Dental will be reduced by the amounts paid for orthodontic treatment by your previous dental care program, if any.

Emergency Care

The Dental Plan provides coverage if you or a covered dependent needs emergency dental care. The Dental Plan will reimburse you up to 100% per visit for emergency treatment when you use a Delta dentist and 80% per visit when you use a non-Delta dentist, up to the plan-year benefit maximum. Emergency treatment should be used for temporary relief of pain only. If additional dental care is required, you should receive routine dental services instead of relying on emergency care.

When you access emergency care, your dentist must provide a description of the nature of the emergency and the treatment you received.


Delta Dental will use the dentist's Statement of Treatment to process the claim, so it's very important that the statement include a description of each service the dentist performs.