Benefit information for Delta Dental DPO
DPO, our Dental Provider Organization plan in Texas provides access
to the largest network of its kind in the U.S. DPO dentists agree
to accept reduced fees for covered procedures when treating DPO
patients. This means you will usually have lower out-of-pocket costs
when you visit a DPO dentist than when you visit a non-Delta Dental
dentist; however, you have the freedom to visit any licensed dentist,
anywhere in the world.
Your Delta Dental plan provides you with a dual-network advantage.
Not only do you have access to DPO dentists you also have access
to the Delta Dental Premier® network. While DPO dentists generally
offer deeper discounts, the Premier network provides you with
access to more dentists than any other carrier in the nation. Delta
Dental dentist also provide other advantages such as filing claim
forms for you and accepting payment directly from Delta Dental.
DPO from Delta Dental offers:
•
•
•
•
•
•
Reduced fees when you visit a DPO dentist
Freedom to choose any licensed dentist, anywhere in the world
The nation’s largest reduced fee-for-service dental network
Contractual protections which shield employees from balance billing and billing for
non-allowable procedures
Dual network access with the Delta Dental Premier safety net
Claims convenience: Delta Dental dentists handle all claims paperwork and most inquiries
for Delta Dental patients
The following pages contain the benefits for your plan.
[2]
SM
Delta Dental PPO – Easy, Friendly, Accessible
We’ll do whatever it takes and then some.
Greatest potential savings
when you visit a Delta Dental
PPO dentist
OUT-OF-POCKET COSTS
SAVE LESS
NON-NETWORK
DENTIST
SAVE MORE
PPO
DENTIST
AMOUNT YOU SAVE
AMOUNT YOU PAY
Illustration showing sample enrollee
share of cost for information purposes
only. Actual dentist fees and contract
allowances will vary by region,
procedure and by group contract.
We’re pleased to be your partner in maintaining great oral health. The Delta Dental PPO*
plan makes it easy for you to find a dentist, and easy to control your costs when you visit a
network dentist. Here are some of the great things you’ll need to know about enrolling with
Delta Dental:
œ Save money with a Delta Dental PPO
dentist. Our PPO network dentists
accept reduced fees for covered
services they provide you, so you’ll
usually pay the least when you
visit a PPO network dentist. This
also ensures Delta Dental dentists
won’t balance bill you the difference
between the contracted amount and
their usual fee.
œ Visit the dentist of your choice.
Want to visit a non-Delta Dental
dentist? No problem. You can visit
any licensed dentist, but your costs
are usually lowest when you see a
PPO dentist.
œ Many network dentists to choose
from. Since Delta Dental offers
access to some of the largest dentist
networks in the U.S., chances are
there’s a wide choice of network
dentists near your home or office.
Four out of five dentists nationwide
are contracted Delta Dental dentists,
giving more enrollees convenient
access to more dentists. Visit us at
www.deltadentalins.com to search
our dentist directory by location
or specialty.
œ Easy to use your benefits.
When you visit a Delta Dental dentist,
pay only your portion for services.
Delta Dental dentists will file claim
forms for you and receive payment
directly from us. Many non-Delta
Dental dentists ask that you pay
the entire cost up front and wait
for reimbursement.
œ Delta Dental’s Online Services make
getting information quick and easy.
Access your benefits and eligibility,
print ID cards and get information
about your claims. And check out
Delta Dental’s oral health resources
too for tips and information that can
help keep your smile healthy.
* In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.
WE KEEP YOU SMILING
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E HL_PPO_ENG_2col_BW #60586 (9/10)
Plan Benefit Highlights for: Austin ISD
Group No: 03595
Effective Date: 9/1/2012
Eligibility
Primary enrollee, spouse and eligible dependent children to age 26
Deductibles*
$50 per person / $150 per family each calendar year—CORE PLAN
$50 per person / $100 per family each calendar year—PLUS PLAN
Yes
Deductibles waived for D & P?
Maximums*
D & P counts toward maximum?
$1500 per each calendar year
No
Basic Benefits
0 Months
Waiting Period(s)
Major Benefits
0 Months
Orthodontics
0 Months
Core Plan
Benefits and
Covered Services**
Delta Dental
†
PPO dentists
Diagnostic & Preventive
Services (D & P)
Plus Plan
Non-DeltaDental
†
dentists
Delta Dental
†
PPO dentists
Non-DeltaDental
†
dentists
100 %
100 %
100 %
100 %
80 %
80 %
90 %
90 %
80 %
80 %
90 %
90 %
Periodontics (gum treatment)
80 %
80 %
90 %
90 %
Oral Surgery
80 %
80 %
90 %
90 %
50 %
50 %
60 %
60 %
NOT A
BENEFIT
NOT A
BENEFIT
50 %
50 %
NOT A
BENEFIT
NOT A
BENEFIT
$ 1,500
$ 1,500
Exams, cleanings, x-rays
Basic Services
Fillings, simple tooth extractions,
sealants
Endodontics (root canals)
Covered Under Basic Services
Covered Under Basic Services
Covered Under Basic Services
Major Services
Crowns, inlays, onlays and cast
restorations, bridges and dentures
Orthodontic Benefits
adults and dependent children
Orthodontic Maximums
Lifetime
Other
* If you switch plans during the calendar year your Deductible and Annual Maximum may be adjusted
accordingly.
** Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees.
†
Fees are based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and
program allowance for non-Delta Dental dentists.
Delta Dental Insurance Company
1130 Sanctuary Parkway, Suite 600
Alpharetta, GA 30009
Customer Service
800-521-2651
Claims Address
P.O. Box 1809
Alpharetta, GA 30023-1809
deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or
Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your
plan, please consult your company’s benefits representative.
HLT_PPO_2COL_HILO_DDIC (Rev. 2 5/11)
D&P Maximum Waiver®
We’ll do whatever it takes and then some.
Preventive care is
the key to good
oral health
The D&P Maximum
Waiver makes it easy for
you to save on your outof-pocket dental costs.
Delta Dental plans have
always emphasized
diagnostic and
preventive benefits, such
as coverage for checkups,
so that you keep your
mouth healthy and
need fewer restorative
services.
Your plan includes the D&P Maximum Waiver benefit, allowing you to obtain
diagnostic and preventive dental services without those costs applying to the
plan year maximum. This benefit promotes good oral health and may reduce
the need for more expensive, restorative dental services that can result from
undetected oral or related health problems.
Easy to use
The annual maximum is waived for
defined diagnostic and preventive
services when you visit any licensed
dentist. There’s nothing for you to
keep track of except for your regular
checkups. When you need more
extensive dental services, there will be
more of your annual benefit amount
remaining for you to use.
What services are included?
Diagnostic and preventive dental
services may include examinations,
x-rays, cleanings and related treatments
as defined by your dental plan. Review
your Evidence of Coverage booklet for
specific coverage details.
The following sample shows the impact on your annual maximum with and without the
D&P Maximum Waiver. Plan benefits and dentist charges vary. Sample assumes two
routine checkups and $1,000 annual maximum.
Without D&P Maximum Waiver
Dental treatment
With D&P Maximum Waiver
Delta Dental
Pays
Enrollee
Pays
Maximum
Remaining
Delta Dental
Pays
$350
$0
$650
$350
Diagnostic & Preventive
(Exams, x-rays,
cleanings): covered at
100% for two visits
Enrollee
Pays
$0
Maximum
Remaining
$1,000
Please review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific
details about your plan.
WE KEEP YOU SMILING®
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Page 1 of 2
WE KEEP YOU SMILING®
How healthy is your smile? Take our online quizzes to find out!
Why do 54 million enrollees trust
their smiles to Delta Dental?
• More dentists
• Simpler process
• Less out-of-pocket
Visit the Oral Health & Wellness section
on deltadentalins.com to take the
following quizzes:
?
Free Newsletter
• Dental Cavity Quiz
• Gum Disease Quiz
Get the latest in oral health
with Dental Wire, our bi-monthly
e-mail newsletter. Sign up at:
deltadentalins.com/oral_health
Questions about oral health?
Connect with us!
facebook.com/deltadentalins
twitter.com/deltadentalins
deltadentalins.com
Delta Dental includes these
companies in these states:
Delta Dental of California – CA
• Delta Dental of Pennsylvania
– PA & MD • Delta Dental of
West Virginia – WV • Delta
Dental of Delaware – DE •
Delta Dental of the District of
Columbia – DC • Delta Dental
of New York – NY • Delta
Dental Insurance Company
– AL, FL, GA, LA, MS, MT, NV,
TX, UT
If you’ve got questions about oral health, be sure to check out our website at
deltadentalins.com for answers.
To help you and your family keep your smiles healthy, we’ve compiled an extensive
library of articles on oral health topics from amalgam fillings to x-rays and just
about every oral health topic in between.
Mouth-Body Connection
• Diabetes and oral health
• Heart disease and oral health
• Men’s oral health
• Oral cancer
• Osteoporosis
• Pregnancy and oral health
• Stress and oral health
• Tobacco use and oral health
Preventive Care
• Brushing and flossing
• Dental cleanings
• Fighting bad breath
• Fluoride
• Nutrition and oral health
• Choosing and caring for
your toothbrush
Emergency Care
• Dental care when traveling
• Handling dental emergencies
Kids & Teens
• Baby bottle tooth decay
• Children’s oral health
• Eating disorders
• Teens’ oral health
Seniors
• Dental care of Alzheimer’s
patients
• Dentures
• Seniors’ oral health
DentalTreatments
• Amalgam and resin fillings
• Braces
• Dental implants
• Dental x-rays
• Sealants
Conditions
• Dry mouth
• Mouth sores
• Sensitive teeth
• TMJ
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E EF27 #63012 (rev. 3/11)
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DELTA DENTAL INSURANCE COMPANY
Client Name: AUSTIN ISD
Group No.: 03595
PARTIAL LIST OF PLAN LIMITATIONS FOR DENTAL PROVIDER ORGANIZATION PLAN (DPO)
Limitations on Diagnostic and Preventive Benefits:
a.
Routine oral examinations and cleanings, including periodontal cleanings, are not provided more than twice in any twelve (12)
month period while the patient is an Enrollee under any Delta Dental or any prepaid dental care program provided by the group
contract holder.
b.
Full-mouth x-rays or panographic x-rays will be provided when required by the Dentist, but no more than once each 5 years will
be paid by Delta.
c.
Bitewing x-rays are limited to two (2) bitewing procedures each twelve (12) months when provided to Enrollees under age 18 and
one (1) each twelve (12) months for Enrollees age 18 and over,
d.
Delta will not pay for topical application of fluoride for anyone 19 years or older.
e.
Space maintainers are limited to the initial appliance only and to Enrollees under age 14.
Limitations on Sealant Benefits:
a.
Sealant Benefits are available only to Enrollees under the age of 16.
b.
Sealants are limited to application to permanent molars with no caries (decay), without restorations and with the occlusal surface
intact.
c.
Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two (2) years of its application.
Limitations on Basic Benefits: - Delta will not pay to replace an amalgam, synthetic porcelain or plastic restorations (fillings) or
prefabricated stainless steel within 24 months of treatment if the service is provided by the same Dentist.
Limitations on Crowns, Jackets and Cast Restorations:
a.
Delta will not pay to replace any crown, jacket or cast restoration which the patient received in the previous five (5) years.
Limitations on Prosthodontic Benefits:
a.
Delta will not pay to replace any bridge or denture that the patient received in the previous 5 years. An exception is made if the
bridge or denture cannot be made satisfactory due to a change in supporting tissues or because too many teeth have been lost.
b.
Delta limits Benefits for dentures to a standard partial or complete denture. A “standard” denture means a removable appliance
to replace missing natural, permanent teeth that is made from acceptable materials by conventional means.
c.
Delta will not pay for implants (artificial teeth implanted into or on bone or gums) or their removal, but Delta will credit the cost of
a standard complete or partial denture that would have been allowed under this plan toward the cost of an implant and related
services (coinsurance apply).
Limitations on All Benefits - Optional services that are more expensive than the form of treatment customarily provided under
accepted dental practice standards are called “Optional Services”. Optional Services also include the use of specialized techniques
instead of standard procedures. For example:
a.
crown where a filling would restore the tooth;
b.
precision denture/partial where a standard denture/partial could be used;
c.
an inlay/onlay instead of an amalgam restoration; or
d.
composite restoration instead of an amalgam restoration on posterior teeth.
If you receive Optional Services, your Benefits will be based on the lower cost of the customary service or standard practice instead of
the higher cost of the Optional Service. You will be responsible for the difference between the higher cost of the Optional Service and
the lower cost of the customary service or standard procedure.
NOTE: THIS IS ONLY A PARTIAL LISTING OF SOME OF THE BENEFIT LIMITATIONS UNDER THE PLAN. The dental health plan contract must
be consulted to determine the exact terms and conditions of coverage. After you enroll, you will receive an Evidence of Coverage which
contains a full explanation of benefits, limitations and exclusions.
FORM # HLT DPO2 DDIC Rev 12/06
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Visit the Delta Dental website: deltadentalins.com
We’ll do whatever it takes and then some.
Convenient services
and information on
our website
™ Log in to:
• Check benefits,
eligibility and
claims status
™
• Print your ID card
Our website* makes it
easy for you to manage
your dental plan. Tools,
services, information,
forms – you’ll find
everything you need
just a click away.
• Find the average
cost of a dental
procedure in your
area
š
š Find a dentist:
• Select your plan
• Enter options
such as state and
ZIP code
• Search for a
dentist and link
to a map with
driving directions
› Oral health information
Read articles, watch
videos, find a glossary
of dental terms and
subscribe to Dental Wire,
our free dental health
newsletter
›
œ

œ Oral Health Quizzes
Assess your risk for
cavities and gum
disease and learn how
to prevent them
 Just for kids
See our kids’ website
also available at
MySmileKids.com
* The website deltadentalins.com is the home of the Delta Dental companies listed on the reverse side and their
subsidiaries and affiliates. For other Delta Dental companies, visit the Delta Dental Plans Association website
at deltadental.com.
WE KEEP YOU SMILING®
Page 1 of 2
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WE KEEP YOU SMILING®
™
›
™
Other tools and information:
Visit the “Use Your Dental Plan”
page for a helpful plan support
guide and answers to frequently
asked questions.
Why do 54 million enrollees trust
their smiles to Delta Dental?
• More dentists
• Simpler process
• Less out-of-pocket
• Download and print a claim
form
• Find general information about
how your plan works
Free Newsletter
• Get instructions for using our
website
Get the latest in oral health
with Dental Wire, our bi-monthly
e-mail newsletter. Sign up at:
deltadentalins.com/oral_health
š
š
• Find quick links to claim,
grievance and customer service
request forms
›
Delta Dental Customer Service
A:
Simply enter your user name and
password in the designated boxes and
submit. If you don’t already have a user
name or password, click the “Register
Today” link to complete the quick threestep registration process:
1. Select “Enrollee” for your user type.
2. Enter your name and other information
in the form.
3. Choose a user name and password
to complete your registration.
Q: Can I contact Delta Dental
through the website?
A:
Q: What if I have trouble logging in
to the website?
A:
California School District Employees
866-499-3001
deltadentalins.com
Delta Dental includes these
companies in these states: Delta
Dental of California – CA • Delta
Dental of Pennsylvania – PA & MD •
Delta Dental of West Virginia – WV
• Delta Dental of Delaware – DE
• Delta Dental of the District of
Columbia – DC • Delta Dental of New
York – NY • Delta Dental Insurance
Company – AL, FL, GA, LA, MS, MT,
NV, TX, UT
Dental Premier® enrollees, please use
the appropriate number listed at the
left to call your local Customer Service.
Q: How do I log in to the website?
Delta Dental of Delaware
Delta Dental of the District of
Columbia
Delta Dental of New York
Delta Dental of Pennsylvania
(and Maryland)
Delta Dental of West Virginia
800-932-0783
Delta Dental Insurance Company
(Alabama, Florida, Georgia,
Louisiana, Mississippi, Montana,
Nevada, Texas, Utah)
800-521-2651
Delta Dental en Español:
• Visit a Spanish version of our
website
DeltaCare® USA
800-422-4234
Delta Dental PPOSM and
Delta Dental Premier®
Delta Dental of California
800-765-6003
Forms and support:
If you have problems, use the Online
Services Login Customer Service Form
to contact us for assistance. You can
find the form on the “Individuals &
Enrollees” page of the website. Scroll
down the “Individuals & Enrollees”
page to find the Forms box on the righthand side of the page. You can find
the Online Services Login Service Form
link at the end of the Customer Service
Forms section.
Yes. You don’t have to log in to contact
us from the website. Simply click on
“Contact us” at the top of the home
page and follow the appropriate links
for your plan. You’ll be presented with
a number of contact options, including
Online Customer Service Request
Forms for specific issues.
Q: How can I check on the average
cost of a dental procedure in my
area?
A:
Log in by entering your user name and
password and click on “Fee Finder” in
the main navigation menu.
Q: How current is the information in
the online dentist directory?
A:
The “Find a Dentist” directory is
updated daily.
Q: What if I don’t have Internet
access?
Q: What if I have more questions?
A:
A:
You can check your benefits, eligibility
and claim information on our
interactive voice response telephone
line or speak to a Customer Service
agent Monday through Friday by calling
Delta Dental toll-free. For DeltaCare®
USA enrollees, please call 800-422SM
4234. For Delta Dental PPO and Delta
For detailed instructions on checking
your benefits and eligibility, finding
a dentist, printing an ID card and
submitting a claim form, visit the “Use
Your Dental Plan” page of our website
for these and other helpful topics.
Page 2 of 2
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E EF30 #62916 (rev. 3/11)
How to print an ID card
1. Go to www.deltadentalins.com
2. Log in to Online Services with your username and password.
(If you don’t already have a username or password, click the
“Register Today” link to complete the quick registration process.)
3. Once you’ve logged in, click the “Eligibility & Benefits” tab.
4. Select “Print ID Card” on the left-hand side of the page. (If you do
not see this option, in some instances you may also need to click
on the “Eligibility & Benefits” link on the left-hand side of the
page before you have the option to select “Print an ID Card.”)
5. Click “Print.”
Go paperless!
We make it easy, so you don’t need an ID card to
receive services.
When visiting your Delta Dental (DPO) or DeltaCare®
USA (DHMO) dentist, simply provide your name, date of
birth and social security or enrollee identification number.
The dental office can use that information to verify your
eligibility and benefits.
Delta Dental’s Mission: To advance dental health and access through exceptional dental benefits service, technology and professional support.
Visit our Delta Dental website at:
www.deltadentalins.com
Delta Dental PPOSM is underwritten by Delta Dental Insurance Company in AL, DC. FL, GA, LA, MS, MT, NV and UT and by notfor-profit dental service companies in these states: CA – Delta Dental of California, PA, MD – Delta Dental of Pennsylvania, NY
– Delta Dental of New York, DE – Delta Dental of Delaware, WV – Delta Dental of West Virginia. In Texas, Delta Dental Insurance
Company provides a Dental Provider Organization (DPO) plan.
DeltaCare® 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, OK, OR, RI, SC, SD, WA, WI, WY — Dentegra Insurance
Company; NH and 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; PA — Delta Dental of Pennsylvania. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these
states, except CA. These companies are financially responsible for their own products. In some states, DeltaCare USA is offered
as an open access plan where enrollees can obtain treatment from any licensed dentist; however, deductibles and maximums
may be applied for services provided by an out-of-network dentist.
EF11 #56417 (rev. 5/10)
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