2012-038 Human Resources - Delta Dental Claims & Administrative fees

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- Fluoride treatments are payable twice per calendar year for people up to age 19. - Sealants are payable once per tooth per lifetime for the occiusal surface of first and second permanent molars up to age 16. The surface must be free from decay and restorations. - Reline and rebase of dentures are payable once in any two-year period. - Implants and implant related services are payable once per tooth in any ftve-year period. - Vestibuloplasty is a Covered Service. - Bitewing X-rays are payable twice per calendar year. Full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period. - Porcelain and resin facings on crowns and onlays are Covered Services on posterior teeth. - Porcelain and resin facings on bridges are Covered Services on posterior teeth. - Composite resin (white) restorations are optional treatment on posterior teeth. - People with certain high-risk medical conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment. Having Delta Dental coverage makes it easy for our enrollees to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment -$1,200 per person total per benefit year on all services except orthodontics. $2,000 per person total per lifetime on orthodontic services. Deductible -$50 deductible per person total per benefit year limited to a ma~cimum deductible of $150 per family per benefit year. The deductible does not apply to diagnostic and preventive services, emergency palliative treahnent, x-rays, sealants, brush biopsy, periodontal maintenance, and orthodontic services. Waiting Period - Employees who are eligible for dental benefits are covered on the first day of the month following date of hire. Eligible People -All eligible employees who have met the eligibility requirements as established by the Contractor. The Contractor and Subscriber share the cost of this plan. Benefits will cease on the last day of the month in which the employee is terminated. Dependents and domestic partners of above mentioned Subscribers are also eligible. Children under age 19 are eligible for benefits regardless of student status and/or disability. Eligibility is extended to age 26 only for children who are full time students. Subscribers and eligible dependents must enroll for a minimum of 12 months. If coverage is terminated after 12 months, they may not re-enroll prior to the open enrollment that occurs at least 12 months from the date of termination. Dependents may only enroll if the Subscriber is enrolled (except under COBRA) and must be enrolled in the same plan as the Subscriber. Plan changes are only allowed during open enrollment periods, except that an election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. A domestic partner is defined as foilows: Domestic Partner - A person of the same or opposite gender, not related by blood to the employee, who is not legally married to the employee or anyone else, and who shares the following with the employee: 1) an exclusive, committed relationship as provided in the Declaration of Domestic Partnership statement, 2) a residence, and 3) responsibility for each otherT"'s common welfare and financial obligations. Customer Service Toll-Free Number: 800-524-0149 www. DeltaDentalNC. co m October 25, 2011