Eligibility and Enrollment 
A subscriber or dependent who drops their coverage, but who still meets all eligibility requirements of the plan, may re-enroll during the first Open Enrollment period after having been out of the plan for 12 consecutive months.

For further definitions of Retiree, Eligible Dependents, and the term Child(ren), refer to the “Glossary” and “About Your Benefits” sections.

Choosing a Dentist
Delta Dental does not directly provide dental services and therefore is not liable for a dentist’s refusal to provide services. It has contracted with “Participating Dentists.”  These dentists are independent contractors who have agreed to accept certain fees for the service they provide to you. Dentists that have not contracted with Delta Dental are referred to as “Non-Participating Dentists.”

Although you are free to choose any dentist, your out-of-pocket expenses may be less if you choose a Participating Dentist. Therefore, you should always ask your dentist if he is a Participating Dentist or verify with Delta Dental that your dentist is a Participating Dentist before receiving any dental services.

Participating vs. Non-Participating
A Participating Dentist’s charges are paid based on Delta Dental’s maximum fee schedule, which providers agree to accept, with no balance billing. This is the Maximum Plan Allowance (“MPA”).

You are responsible for charges exceeding the MPA if you go to a Non-Participating Dentist. The MPA charges are based on fees charged in your geographic area. For example, non-participating providers are generally reimbursed at the 51st percentile of Delta Dental’s prevailing fee schedule as submitted by all providers (based on an overall scale of 100, the maximum payment is paid at or below the 51st percentile).

Annual Deductible
You and each covered dependent must satisfy a $50 individual deductible each calendar year before benefits become payable toward Type B (basic) services and Type C (major) services covered by the plan. There is no deductible for Type A (preventive and diagnostic) services or Type D (orthodontic services).

Maximum Benefits
The plan pays up to a maximum of $1,500 per year for each covered person for Type A, Type B, and Type C expenses combined. There is no lifetime maximum limit for Type A, Type B, and Type C covered expenses. For Type D (orthodontic) services, there is a separate lifetime maximum of $1,500 in benefits for each covered person.

Emergency Dental Care
If you require emergency dental care, you may seek services from any dentist. Your out-of-pocket expenses may be less if you choose a Participating Dentist.