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Benefit highlights
Welcome to
DeltaCare USA
Alpha Dental Programs is a single service (dental) HMO
that provides you and your family with quality dental
benefits at an affordable cost. The DeltaCare USA
program is designed to encourage you and your family
to visit the dentist regularly to maintain your dental
health.
When you enroll, you select a contract dentist to provide
services. The DeltaCare USA network consists of private
practice dental facilities that have been carefully
screened for quality.
SCTX(2005)
Quality
• Extensive benefits for you and your family
• No restrictions on pre-existing conditions,
except for work in progress
• Large, stable network of dentists, so you can
enjoy a long-term relationship with your dentist
Convenience
• No claim forms to complete
• Easy access to specialty care
• Expanded business hours for toll-free customer
service, from 7 a.m. to 8 p.m., Central time
Cost savings
•
•
•
•
No deductibles
Out-of-pocket costs are clearly defined
Emergency dental services coverage
No annual or lifetime dollar maximums
HL_DCU_TX15B_V9_10.27.2009
Highlights of your DeltaCare USA Program
Eligibility for you and your family
If you meet your group's eligibility requirements for dental coverage, you can enroll in
the DeltaCare USA program. You may also enroll eligible dependents. Contact your
benefits administrator if you have any questions.
What if I have
questions about
my DeltaCare USA
Program?
Easy enrollment
Simply complete the enrollment process as directed by your benefits administrator. Be
sure to indicate a dentist (from the list of contract dental facilities) for both yourself and
your eligible dependents. Include the name of your group.
How your DeltaCare USA program works
Your selected contract dentist will take care of your dental care needs. If you require
treatment from a specialist, your contract dentist will handle the referral for you.
After you have enrolled, you will receive a membership packet that includes an
identification card and an Evidence of Coverage that fully describes the benefits of your
dental program. Also included in this packet are the name, address and phone number
of your contract dentist. Simply call the dental facility to make an appointment.
Under the DeltaCare USA program, many services are covered at no cost, while others
have copayments (amount you pay your contract dentist) for certain benefits. See the
"Description of Benefits and Copayments" for a list of your benefits.
Please note: Dental services that are not performed by your selected contract dentist, or
are not covered under provisions for emergency care below, must be preauthorized by
us to be covered by your DeltaCare USA program.
Provisions for emergency care
e
Under your DeltaCare USA program, you are covered for emergency dental services as
described in the "Description of Benefits and Copayments."
My dentist is a Delta Dental dentist but is not on the list of DeltaCare USA
dentists. Can I still receive treatment from this dentist?
You must receive treatment from your selected DeltaCare USA contract dentist. Please
note that Delta Dental dentists are not necessarily DeltaCare USA dentists.
Do my family members receive treatment from the same DeltaCare USA contract
dentist?
You and your eligible dependents may receive care from the same contract dentist, or if
you prefer, you may select individual contract dental facilities.
Can I change my contract dentist?
You may change contract dentists by notifying us either by phone or in writing, or by
visiting our web site (www.deltadentalins.com). If you contact us by the 21st of the
month, the change will become effective the first of the following month.
How long does it take to get an appointment with a DeltaCare USA dentist?
Three weeks is a reasonable amount of time to wait for a routine, non-urgent
appointment. If you require a specific time, you may have to wait longer. Most DeltaCare
USA dentists are in private group practices, which means greater appointment
availability and extended office hours.
Does my DeltaCare USA program cover tooth-colored fillings and crowns?
Porcelain and other tooth-colored materials are included as a benefit under your
program. Your out-of-pocket cost for this service is shown in the "Description of Benefits
and Copayments."
1
Highlights of your DeltaCare USA Program
Can I have my teeth whitened under the DeltaCare USA program?
External bleaching is a benefit under your program. See the "Description of Benefits and
Copayments" and talk to your contract dentist about your options.
Are pre-existing dental conditions and work in progress covered?
Treatment for pre-existing conditions, such as extracted teeth, is covered under the
DeltaCare USA program. However, benefits are not provided for any dental treatment
started before joining the program (that is, work in progress, such as preparations for
crowns, root canals and impressions for dentures). Orthodontic treatment in progress
may be covered for new DeltaCare USA enrollees. See the "Limitations and Exclusions
of Benefits."
How does the DeltaCare USA program encourage preventive care?
Your DeltaCare USA program is designed to encourage regular visits to the dentist by
having no copayments (fees you pay to the contract dentist) on most diagnostic and
preventive benefits. See the enclosed "Description of Benefits and Copayments."
Does my DeltaCare USA program cover specialists' services?
Your contract dentist will coordinate your specialty care needs for oral surgery,
endodontics, periodontics or pediatric dentistry with an approved contract specialist.
There is no additional charge to you for receiving care from a specialist. If there is no
contract specialist within your service area, a referral to an out-of-network specialist will
be authorized at no extra cost, other than the applicable copayment.
What if I have questions about my DeltaCare USA program?
Call Customer Service at 800-422-4234. We have multilingual representatives available
from 7 a.m. to 8 p.m. Central time, Monday through Friday. Our Customer Service
representatives have worked in dental facilities and can answer benefits questions, as
well as arrange facility transfers and urgent care referrals.
e
e
Our Customer Service
representatives have
worked in dental
facilities and can
answer benefits
questions, as well
as arrange facility
transfers and urgent
care referrals.
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Sample Office Visits
CODE
Sample visit #1
D0999
D0150
D0210
Sample visit #2
D0999
D0160
D0210
D1120
Sample visit #3
D0999
D0160
D0210
D7111
D9215
Sample visit #4
D0999
D2140
D2330
D9215
Sample visit #5
D0999
D0160
D2791
ENROLLEE
PAYS
DESCRIPTION
Office Visit
Comprehensive oral exam
X-rays
TOTAL
$5.00
No Cost
No Cost
$5.00
Office Visit (6 mo. check up)
Detailed oral exam
X-rays (if needed)
Prophylaxis - child
TOTAL
$5.00
No Cost
No Cost
$5.00
$10.00
Office Visit
Detailed oral exam
X-rays
Single tooth extraction
Local anesthetic
TOTAL
$5.00
No Cost
No Cost
$10.00
No Cost
$15.00
Office Visit
One surface amalgam filling
One surface resin filling
Local anesthetic
TOTAL
$5.00
$8.00
$22.00
No Cost
$35.00
Office Visit
Detailed oral exam
Crown - full cast predominantly base metal
(May require build-up at additional cost)
TOTAL
10
$5.00
No Cost
$295.00
$300.00
Limitations and Exclusions of Benefits
SCHEDULE B
Limitations of Benefits
1.
The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and
Copayments.
2.
If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge
pontics and/or bridge retainers, the Enrollee may be charged an additional $100.00 above the listed Copayment for each of these
services after the sixth unit has been provided.
3.
General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction
with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241).
4.
Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract
Dentist to treat the child and upon prior authorization by Alpha, less applicable Copayments. Exceptions for medical conditions,
regardless of age limitation, will be considered on an individual basis.
5.
The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on
the Contract Orthodontist's usual fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of
months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged.
6.
Orthodontic treatment in progress is limited to new Enrollees who, at the time of their original effective date, are in active treatment
started under their previous employer sponsored dental plan, as long as they continue to be eligible under this program. Active
treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their
prior dental plan. Alpha is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.
Exclusions of Benefits
1.
Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments.
2.
Any procedure that in the professional opinion of the Contract Dentist:
a.
has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or
surrounding structures, or
b.
is inconsistent with generally accepted standards for dentistry.
3.
Services solely for cosmetic purposes, with the exception of procedure D9972, External bleaching, per arch, or for conditions that
are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing
teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth
abnormalities.
4.
Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed partial dentures (bridges) for children
under 16 years of age.
5.
Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers, crowns and fixed partial dentures
(bridges).
6.
Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of
the temporomandibular joint (TMJ).
7.
Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth,
precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and
personalization and characterization of complete and partial dentures.
8.
Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated
with a dental implant.
9.
Consultations for non-covered benefits.
10. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a
Contract Orthodontist except for Emergency Dental Services as described in Schedule A.
11. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care
facility.
12. Prescription drugs.
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Limitations and Exclusions of Benefits
13. Dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee's eligibility with this
program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has
been taken and orthodontics unless qualified for the orthodontic treatment in progress provision.
14. Lost, stolen or broken orthodontic appliances.
15. Changes in orthodontic treatment necessitated by accident of any kind.
16. Myofunctional and parafunctional appliances and/or therapies.
17. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard
fixed and removable orthodontic appliances.
18. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.
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Glossary
The following dental terms have the meanings indicated:
Abrasion - The abnormal wearing away of the tooth by chewing, incorrect brushing methods, grinding or
similar causes.
Alveoloplasty - A surgical procedure to reshape the jaw bones to achieve normal bone contour in preparation
for tooth replacement via denture, partials or bridges.
Amalgam - A metal alloy used in filling teeth.
Apicoectomy - The surgical removal of the root tip.
Appliance - A device used to provide function or therapeutic effect.
Attrition - The normal loss of tooth substance resulting from friction during chewing.
Banding - Application of preformed stainless steel rings that are fitted around the teeth and cemented in
place.
Banding dentition - Treatment of a tooth which involves banding (for orthodontic purposes).
Cephalometric x-rays - X-rays used in studying the measurements of the head in relation to specific soft
tissue and bony reference points.
Cleft palate - A birth defect resulting in an incomplete closure or formation of the palate.
Debridement - The removal of plaque and tartar, above and below the gumline, which makes the ability to
evaluate the gum condition difficult.
Equilibration - Changing the occlusal forms of the teeth by selective grinding, with the interest of balancing
occlusal stresses more evenly on the teeth.
Erosion - Chemical or mechanical destruction of tooth substance, the mechanism of which is incompletely
known, that leads to the creation of a depression in the tooth surface at the gumline.
Exostosis - An excessive growth of bone.
Expansion appliance - An appliance used to widen a dental arch to increase the room available for
permanent teeth and/or to correct the bite.
Frenum - The fibers that attach the cheek, lips or tongue to the tissue lining the mouth.
Frenectomy - Surgical removal or loosening of the frenum.
Functional appliance - An appliance used to achieve minor tooth movement, to strengthen the muscles of the
oral cavity or to maintain space created by the loss or delayed eruption of the teeth.
Gingiva - The soft tissue which covers a tooth or the gum surrounding a tooth.
Gingivectomy - The surgical removal of the unsupported gingiva to the level where it is attached.
Gingivoplasty - Surgical contouring of the gingiva to facilitate maintenance of tissue health and integrity.
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Glossary
Headgear - An apparatus encircling the head or neck that provides attachment for an intraoral appliance in
use of extraoral anchorage.
Implant - A device specially designed to be placed surgically within or on the mandibular or maxillary bone
as a means of providing for dental replacement of a missing tooth.
Lingual - Pertaining to the tongue.
Macrognathia - A definite overgrowth of the mandible and maxilla.
Mandible - The lower jaw.
Mandibular - Pertaining to the lower jaw.
Maxilla - The upper jaw.
Maxillary - Pertaining to the upper jaw.
Micrognathia - An abnormal smallness of the jaws, especially the mandible.
Myofunctional therapy - Training to curb or eliminate abnormal muscle function of the oral cavity.
Occlusal - The chewing surfaces of the posterior teeth.
Occlusion - The contact between the upper and lower teeth when in a closed position.
Orthodontic appliance - Any appliance used to apply forces for tooth movement during orthodontic
treatment.
Palate - The roof of the mouth.
Palatal - Pertaining to the roof of the mouth.
Palliative - Action that relieves pain but does not cure the cause of the pain.
Panoramic film - An x-ray that offers a full view of the entire length of the jaws in a single x-ray.
Pediatric or Pedodontic - Pertaining to children.
Periapical - The area surrounding or enclosing the root tip of a tooth.
Periodontitis - Gingival changes that occur due to infection and loss of attachment between the tooth and
gums. Periodontitis is a long-term progressive disease.
Periradicular - Around the root.
Pontic - The term used for the artificial tooth on a bridge.
Prophylaxis - The removal of plaque, tartar and stains on the crown portion of the teeth, including polishing.
Pulp cap - The covering of an exposed dental nerve with material that protects it from foreign irritants.
14
Glossary
Quadrant - One of the four equal sections into which the dental arches can be divided; begins at the middle
of the arch and goes to the last tooth on either side.
Rebase - Process of refitting a denture by replacing the acrylic base material.
Resin - Broad term used to indicate an organic substance that is usually tooth colored. Composite resin used
in filling teeth, most often in the front of the mouth.
Retainer - An appliance used to maintain the positions of the teeth and jaws gained by orthodontic
procedures.
Retrograde filling - A method of sealing the root canal by preparing and filling it from the root tip.
Root planing - A procedure designed to remove bacteria, tartar and diseased root tissue from the root
surfaces. Often referred to as “deep cleaning.”
Sealant - Application of a resin material to the biting surfaces of the permanent molars to seal the surface
crevices to prevent the formation of decay.
Study model - A positive likeness of dental structures (teeth and adjoining tissues) for the purpose of study
and treatment planning.
Supernumerary - Any tooth in excess of the 32 normal permanent teeth.
Temporomandibular joint - The joint formed by the connection of the lower jaw to the skull.
Tracing - As it relates to orthodontic treatment, a tracing is a line drawing of pertinent features of a
cephalometric x-ray made on a piece of transparent paper placed over an x-ray. The tracing provides
measurements of soft tissue and bony reference points that aid in predicting growth patterns and
orthodontic diagnosis and treatment planning.
Trigeminal nerve - The main nerve that provides feeling to the muscles and tissues of the face, jaws and
teeth.
Vertical demension - The vertical height of the face with teeth in occulusion.
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NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.
The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of Coverage will be sent to you upon enrollment. If you wish to review an Evidence of Coverage prior
to enrollment, you may request a copy by calling the Customer Service department at 800-422-4234.
In Texas, DeltaCare USA is underwritten by Alpha Dental Programs, Inc. and administered by Delta Dental Insurance
Company. These companies are financially responsible for their own products.
Customer Service
12898 Towne Center Drive
Cerritos, CA 90703-8546
800-422-4234
Monday through Friday
7 a.m. to 8 p.m., Central time
Provided by:
Alpha Dental Programs, Inc.
700 Parker Square, Suite 150
Flower Mound, TX 75028
www.deltadentalins.com