Basic Plan Insurance Policy from Delta Dental
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| Basic Plan Insurance Policy from Delta Dental
Dental benefits are important to you and those around you, so thank you for recognizing this and buying benefits from Delta Dental.
Dental benefits are important, and so is this document. That’s why it’s important you read it, start to finish. We’ll try to make it as painless as possible. Also, please hold on to this document. It can answer many questions about your dental insurance.
“You” refers to the person who bought this policy. Any information about this policy will come to you. If you did not buy this policy you will not receive any information from Delta Dental about this policy.
Your declaration page is part of your policy. Read it. If it’s wrong, let us know. It may affect your coverage.
This policy from Delta Dental of Wisconsin, Inc. only covers Wisconsin residents, and is governed by Wisconsin law on limited-scope dental policies. If you’re not a Wisconsin resident this policy doesn’t cover you. However, if you tell us what state you live in we may be able to refer you to a different Delta Dental policy.
This policy covers only what it says it covers. Everything else is not covered, whether or not it’s listed as “not covered.”
Delta Dental settles claims based on a payment system that may be less than what you are billed by the dentist. Please see the “Choosing A Dentist” section for more details.
If you’re not satisfied with this policy you can return it anytime within 10 days of the day you received it. We’ll void the policy and refund your money, less any payment for claims you incurred.
00230 001.000^^ Now, about your questions …
At the earliest, your coverage starts the first day of the month after your application is approved. Your declaration page will show your effective date.
It continuously renews unless we choose to not renew your coverage, or you tell us you no longer want the coverage. What if I have other dental insurance? If you have other dental insurance you can’t buy this dental insurance.
Your children and spouse can be covered under this policy as long as they’re eligible. If they’re no longer eligible (but still Wisconsin residents), they can purchase their own policy. Please see the Who Is Eligible For Coverage section for details.
If you’d like to keep this coverage all you need to do is pay the premium. This policy will automatically renew.
At www.DeltaDentalCoversMe.com
you can make address or payment changes, or add or remove people you want to cover with this policy. You can find out about your premium and effective date, and see and print information about your policy, ID card, benefits and claims.
Delta Dental has a Maximum Plan Allowance (MPA) for benefits, which is the highest amount Delta Dental will pay for dental procedures. Delta Dental PPO and Delta Dental Premier Dentists have agreed to accept the MPA for any covered procedure and you will not have to pay for any amount above that.
If you see a Delta Dental PPO dentist, the amount you pay is based on a reduced fee which is usually less than if you see other dentists. If you see a Delta Dental Premier dentist, Delta Dental pays up to the Maximum Plan Allowance. You will always pay the Office Visit Copay, deductibles, coinsurance, optional procedures, and any services not covered by this policy. 00230 001.000^^ If you see a dentist that is not in the Delta Dental Premier or Delta Dental PPO network, you will have to pay any balance remaining after Delta Dental pays up to the Maximum Plan Allowance. Find a listing of more than 1,000 Delta Dental PPO dentist locations in Wisconsin and hundreds of thousands of Delta Dental network dentists nationwide at www.DeltaDentalCoversMe.com, or call 888-899-3734.
What follows is a list of the dental procedures covered under this policy. If a procedure isn’t listed below, it’s not covered.
Each time you, or a person covered under this policy visits a dentist to receive services covered under this policy, you must pay the dentist a per person Office Visit Copay of $15.
The policy period starts on your enrollment date and continues for 12 months after that. This time period is also called the “benefit accumulation period.”
The maximum total benefit that can be paid in any benefit accumulation period is $1,000 for you and for each covered dependent.
This policy doesn’t include any major services such as root canal, crowns, dentures, implants, etc.
This policy doesn’t include an orthodontic benefit. This policy provides benefits according to the coverage percentage listed in the following chart, after the Office Visit Copay is paid.
In the following chart, if the coverage percentage shown is “50,” Delta Dental will pay 50% of the amount Delta Dental allows, after the office visit copay is paid. In this case, the coinsurance —the amount the patient must pay – is 50%.
Any waiting periods will be waived for you if you were covered under another comprehensive dental-insurance plan for at least 12 months before you enrolled in this plan – but only if there was no more than a 63-day gap between your previous plan and this plan. (You may have to supply information about your previous plan to make sure you qualify for waived waiting periods.) Waiting periods will not be waived for new members added to this policy, unless they were covered under another comprehensive dental insurance plan for at least 12 months before they enrolled in this plan, and if there was no more than a 63-day gap between their previous plan and this plan. 00230 001.000^^ Coverage Percentage What is covered (for each person covered under the plan) Diagnostic, Preventive and Emergency Dental Procedures 100 Examination or evaluation, once every six months. 100 Simple cleanings, once every six months. 100 Bitewing X-rays, one set every 12 months, limited to a set of 4 films 50 Fluoride (for ages 14 and under), once every 12 months. 50 Full-mouth X-rays once every five years (a series of individual X- rays or a panoramic X-ray).
Sealants on the decay-free, biting surface of permanent molars, one sealant per tooth per lifetime, for ages 14 and under.
Space maintainers when a primary molar tooth is prematurely lost. 50 Emergency treatment to relieve pain. 50 Emergency evaluation, once every 12 months. A 6 month waiting period applies to the following procedures. 50 Composite (tooth-colored) fillings on front teeth. Amalgam (silver- colored) fillings on back teeth. Replacing an existing filling is covered once every two years. 50 Non surgical extractions. 00230 001.000^^ Optional Procedures We pay for the least expensive dental procedure necessary to fix the problem, as outlined in the section What Is Covered and What You Pay. You have to pay the rest of the dentist’s fee if a more expensive dental procedure is selected.
1.
Cosmetic services or supplies, including cosmetic work done on dentures. 2.
Any procedures done to restore the height and/or width of teeth. 3.
General anesthesia and/or intravenous (deep) sedation, except when this policy says otherwise. 4.
5.
Oral surgery, including surgical extractions. 6.
Endodontics, periodontics, crowns, bridges, partial and complete dentures, implants. 7.
Preventive control programs. 8.
Injuries or conditions covered under Workers’ Compensation or Employer's Liability laws; services provided by any government agency; or any services that are provided free. 9.
Treatments that are still under investigation or observation. 10.
Prescription drugs. 11.
12.
Hospitalization charges and related charges. 13.
Consultations or second opinions. 14.
Charges for missed appointments. 15.
Patient management problems. 16.
Charges for completing claim forms. 17.
Habit-breaking appliances. 18.
Temporomandibular joint (TMJ) services or supplies. 19.
Brushing and flossing instructions, tobacco and nutritional counseling. 20.
Any dental services provided to anyone covered under this policy while they are on active service in the Armed Forces. 21.
Any dental services to treat injuries or diseases caused by any form of civil disobedience or criminal act, or any injuries intentionally inflicted. 00230 001.000^^ 22.
Any dental services performed or started before this policy took effect. 23.
Any dental services performed or started after this policy ends. 24.
Laboratory tests and/or laboratory examinations. 25.
Procedures provided by someone other than a dentist or licensed hygienist employed by a dentist. 26.
Anything determined (by Delta Dental) not to be necessary for treating a dental condition, disease or injury. 27.
Replacement of a lost, missing or stolen denture or bridge. 28.
29.
Repair or replacement of orthodontic appliances. 30.
Free services or supplies. 31.
Services covered or provided under any other plan or policy. 32.
Claims not submitted within 15 months of the date of service. 33.
Services not listed in this policy as a benefit. Who is Eligible for Coverage If you are a Wisconsin resident age 18 and older who has no other insurance covering dental procedures, you may buy this policy. You can also include the following people under your policy:
1. Your legal spouse; 2. Your legal dependents, married or unmarried, up to the end of the month when they turn 26.
Coverage for A Newborn/Adopted Child If you enroll and have family coverage, a newborn child is covered at birth and coverage continues for 60 days. You have a year to add the newborn to the policy if you pay the premium plus 5-1/2% interest. The policy will pick up coverage at any point during the newborn’s first year of life. If you adopt a child, coverage begins the first of the month following the date the child is adopted, placed for adoption, or on the day of the final order granting adoption, whichever comes first.
00230 001.000^^ Adding or Removing Dependents
Any person you want to cover under this policy and is not an adoptee or newborn as described above has to apply to be added to this policy as a covered dependent. If the application is accepted, the covered dependent will be added on the next anniversary of your policy’s effective date and you will be billed at that time.
Mailing or emailing information to Delta Dental is sufficient. Information sent to you will be considered sufficient if sent to your last known physical address or email address.
Your premiums for this policy will be shown on the declaration page. You are responsible for paying premiums. The first premium is due the day we accept your application for coverage. You can pay premiums monthly, semiannually or annually. That time is called a “premium period.” Premiums are due the first day of each premium period. If the charge is declined on the due date, we will tell you, and you have to take care of paying the premium. If at the end of a 31-day grace period your account is still overdue, we will cancel your coverage. Delta Dental may change the rates and/or benefits under this policy on this policy’s renewal date. Delta Dental will send you notice of a rate change at least 30 days before the change takes effect. However, if we increase your rate 25% or more, or if we decrease any benefits under your policy, Delta Dental will send you notice of the new rate and benefits at least 60 days before the change takes effect. This policy is valid for 12 months. When you buy this policy, you are committing to keeping it in force for at least 12 months, starting with the policy's effective date as shown on the declaration page. After that, you can renew this policy for another 12 month period under the following circumstances: if we agree, if you remain eligible, and if premiums are paid according to the procedure described above.
Unless you have told us you want to terminate your policy, because of a qualifying event, you have a 31-day grace period to pay your premium. You are still covered during the grace period. If you don’t pay your premium within the grace period, you will lose coverage on the last day of the grace period. You have to pay for coverage provided during the grace period.
If we terminate this policy for nonpayment of premium and we accept a premium payment from you within one year after the date the policy was terminated, we will reinstate this policy. The effective date will be the date we accepted the premium. 00230 001.000^^
Once we reinstate this policy, we will not cover any dental services performed between the date the policy was terminated and the date it was reinstated. Note that we may charge you a reasonable reinstatement fee. In all other respects, we will treat your reinstated policy as if it never was terminated, unless we disclose to you any special provisions in connection with the reinstatement.
After an exam, your dentist may recommend a treatment plan. If you are wondering what the treatment will cost, ask your dentist to send the treatment plan, with X-rays, to Delta Dental.
After we receive the treatment plan, we will estimate how much each of us will pay, and we will send you and your dentist an
estimate. If you have any questions about the estimate, just call us at 888-899-3734.
Before you begin the treatment plan, you and your dentist should discuss the plan, the amount Delta Dental will pay, and how you will pay the remainder.
To file a claim with Delta Dental, show your ID card to the receptionist at your dentist’s office. You or your dentist should file your claim with us within 90 days after you see the dentist.
We’ll tell you what we paid -- called an Explanation of Benefits -- within 30 days after we receive your claim, unless special circumstances require more time. If we deny a claim because we need more information, the Explanation of Benefits shows what additional information we need. Claims need to be filed within 15 months after a procedure is incurred for Delta Dental to consider them for payment. Dental Procedure Incurred A dental procedure is incurred on the date it is completed. Delta Dental pays upon completion of a procedure. The completion date has to be listed on the claim.
Non-Urgent Care Situations: If anyone covered under this policy makes a claim and we deny some or all of it, we’ll give written notice to you, or the person who made the claim, or the dentist who provided treatment. Our claim decision will be provided on an Explanation of Benefits form.
We usually give written notice within 30 days. If we need more time, we’ll tell you, or the person who made the claim, and the dentist. If we need more information, we’ll describe the 00230 001.000^^ additional information we need. You, or the person who made the claim, or the dentist, then have 45 days to give us the information we need. Appealing a Claim Denial
If anyone covered under this policy has questions about a denied claim, call Delta Dental at 888-899-3734. Most questions about benefits can be answered informally, so please call first and talk with us. However, you, or a person covered under this policy, have the right to file an appeal asking us to formally review the benefits decision.
If you aren’t satisfied with the way Delta Dental provided services or handled claims under this policy, anyone covered under this policy, or their representative, can file a written complaint with us. This is called a “grievance.”
To file a grievance or appeal a benefits determination, contact our benefit services department at 888-899-3734, fax your request to 800-807-1970, or mail it to:
Delta Dental P.O. Box 103 Stevens Point, WI 54481-0103
Include the reasons why you disagree with our benefits determination and include any evidence you believe supports your claim. Include your name, the name of the covered person if applicable, and your policyholder ID number on all supporting documents.
We will let you know we received the grievance or appeal within five days after we receive it. We will try to resolve the grievance or appeal informally. If we can’t, you, a person covered under this policy, or a representative, may appear before our grievance committee to present your information and ask questions of the committee. The committee will tell you, the covered person, or a representative the time and place of the meeting at least seven calendar days before the meeting.
If someone covered under this policy does not go through the process described above, and you file a lawsuit against us seeking payment of benefits, the court may not allow the lawsuit to proceed. No legal action can be brought against Delta Dental more than three years after the grievance committee’s final decision. 00230 001.000^^ Time Limits for Resolution We’ll try to resolve all grievances and benefit-determination appeals within 30 calendar days. We will tell you, or the covered person, our decision in writing. If the appeal is denied in whole or in part, the notice will include: 1.
The specific reason(s) for the denial; 2.
The specific part(s) of the policy, the scientific or clinical judgment, or the processing policy on which the denial is based; 3. A statement that you are entitled to receive, free for the asking, access to and copies of all documents, records, and other information relevant to the claim; and 4. A statement describing our appeal procedure. We usually resolve grievances within 30 days. If we can’t, we will tell you, or the covered person, or your representative, in writing that we need an additional 30 days to resolve the grievance. We will resolve all grievances and appeals within 60 days from the date that we receive them.
Delta Dental’s grievance committee consists of a consultant chosen by Delta Dental, a representative of Delta Dental management, Delta Dental’s claim administrator, and a policyholder who is not a Delta Dental employee.
If you disagree with the way Delta Dental handled a situation that needed immediate dental attention, you can send us an urgent-care grievance. We will accept an urgent-care grievance from you, a person covered under the policy, or a representative, in writing, in person, or by telephone. Grievances can be directed to:
Delta Dental P.O. Box 103 Stevens Point, WI 54481-0103 888-899-3734
If
we can’t resolve an u rgent
-c are
g rievance informally within 48 hours after receiv ing it, you
, a covered person, or a representative may appear before o ur g rievance c ommittee to present your information and ask questions of the c ommittee.
We will resolve an urgent-care grievance within 72 hours of the time we receive it. 00230 001.000^^ Terminating This Policy Termination by Policyholder When you buy this policy you are committing to keeping it in force for at least 12 months. You can terminate this policy sooner only for the following reasons:
1. You become covered under another dental plan. If anyone else covered under this policy becomes covered under another dental plan, they may be terminated without terminating the entire policy. When you or your dependent get coverage under another dental plan, proof of coverage may be required prior to terminating from this plan. 2.
You enter full-time United States military service. If a person covered under this policy other than you enters military service, you may terminate their coverage without terminating the entire policy.
Thirty days in advance of the date you wish to terminate you have to tell us in writing (either electronically or through the mail) that any of the above events occurred and you want us to terminate your dental insurance. If you do, we will refund your unused premium.
In the event of your death, anyone else covered under your policy who meets eligibility standards may choose to continue coverage by applying for a new policy. If a covered person other than you dies, you can terminate their coverage without terminating the entire policy.
We can terminate your policy before its annual renewal for the following reasons:
1.
You don’t pay the premium when it’s due. 2.
You or a covered dependent commits fraud or lies about something having to do with your dental insurance. 3.
4.
You or a covered dependent doesn’t comply with the policy, or are no longer eligible. If we terminate your dental insurance, we will refund your unused premium. Nonrenewal This policy will automatically renew. If you don’t want to renew this policy, send us written notice (either electronically or through the mail) before the policy’s renewal date. If you do, this policy will end on the last day before the renewal date. We can nonrenew this policy by sending you written notice (either electronically or through the mail) at least 60 days before the renewal date. If we do, this policy will end on the last day before the renewal date.
00230 001.000^^ Effective Date of Termination All insurance for you and/or other people covered under this policy stops on the date this policy is terminated. That date is:
1. The day following the grace period, if the premium hasn’t been paid; or 2.
date stated in your request (if we approve of this date); or 3.
The last day before the renewal date if either we or you don’t renew this policy; or 4.
The last day of the month of the date of your death; or 5.
The last day of the month of the date of death of a person covered under this policy other than yourself, but only for that person; or 6.
to anyone covered under this policy. If your coverage under this policy is terminated for any reason, and not reinstated by us prior to the coverage expiration date, you cannot sign up for a Delta Dental individual policy for 24 months from the date of termination.
If anyone covered under this policy commits fraud or lies about something having to do with your dental insurance, we may terminate your coverage back to its original effective date. If we do that, we’ll give back the premium you paid us minus any claims we paid and a reasonable administration fee. If the claims we paid are more than the premium you paid, you have to pay us the difference. Delta Dental’s Liability We are not responsible for the actual care you receive from anyone. This policy does not give anyone any claim, right, or cause of action against us based on what a provider of dental care, services or supplies does or doesn’t do.
If we pay benefits under this policy, and you are paid by someone else for the same procedures we pay for, we have the right to recover what we paid. You have to sign and deliver to us any legal papers relating to the recovery.
Any notice sent to Delta Dental must be sent in writing (either electronically or through the mail). It’s considered delivered when sent to us at the e-mail address shown below; when given 00230 001.000^^ in person; or when sent registered or certified United States mail, return receipt requested, proper postage prepaid, and properly addressed to:
Delta Dental P.O. Box 103 Stevens Point, WI 54481-0103 Email: customerservice@deltadentalcoversme.com
This policy is issued and delivered in the State of Wisconsin and obeys its laws and regulations. If it conflicts with any of Wisconsin’s laws and regulations it will automatically conform to the state’s minimum requirements.
If we don’t exercise any remedy or right under this policy, that doesn’t affect our ability to exercise any remedy or right at any time in the future.
The entire contract of insurance between you and us consists of this policy, the declaration page, the application, and any and all endorsements and riders.
No oral statements by anyone can change or affect any aspect of this policy. Notice of Legal Action No legal action can be brought against us until at least 60 days after proof of loss has been furnished, or that proof of loss has been waived, or we have denied payment, whichever comes earlier.
If you have problems with any insurance company or agent, contact them to resolve your problem. You can contact Delta Dental at the following address and telephone number:
Delta Dental P.O. Box 103 Stevens Point, WI 54481-0103 888-899-3734
The Office of the Commissioner of Insurance is a state agency that regulates Wisconsin insurers. To file a complaint with the Office of the Commissioner of Insurance, write to:
00230 001.000^^ Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873
Or you can request a complaint form by calling one of these numbers: 800-236-8517 outside Madison 608-266-0103 in Madison 00230 001.000^^
KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? – If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem. Delta Dental of Wisconsin, Inc. P.O. Box 103 Stevens Point, WI 54481 888-899-3734 You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin’s insurance laws, and file a complaint. You can file a complaint electronically with the OFFICE OF THE COMMISSIONER OF INSURANCE at its website http://oci.wi.gov, or by contacting: OFFICE OF THE COMMISSIONER OF INSURANCE Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 800-236-8517 608-266-0103 SS335-1802 00230 001.000^^ Document Outline
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