Paying For Your Care

Whether you see a Delta dentist or a non-Delta dentist, the plan covers the same broad range of dental services, including emergency dental care. However, the amount you pay for each service depends on the type of provider you see. Let's take a closer look at what your charges will include.

Deductible
Before the plan begins to pay benefits, you must meet either an individual or a family calendar-year deductible for most services. In addition, there's a separate lifetime deductible for orthodontia treatment.

There's no deductible for diagnostic and preventive care. That means you can receive diagnostic and preventive care services without first meeting your deductible.

There's a maximum family deductible for each plan year. Once two covered family members meet their individual deductibles, the family maximum has been met. That means that no other covered family member is required to meet his/her individual deductible for that plan year before benefits are paid.

Coinsurance
Once you meet the deductible, the plan pays a percentage of the dental service, and you pay the rest. This is called coinsurance. You're responsible for a higher coinsurance when you see a non-Delta dentist.

Reasonable And Customary (R&C) Limits
R&C limits are maximums for charges considered reasonable and customary based on what 80% of providers in your geographic area charge for similar services or supplies. (A "geographic area" is an area grouped by several ZIP codes.)

R&C limits apply only when you see a non-Delta dentist. The plan doesn't cover charges above R&C limits - they're your responsibility. To find out whether your non-network dentist's charges fall within R&C limits for a specific service before you receive care, ask your dentist to submit a predetermination of benefits to Delta Dental which describes the anticipated service and charges. Delta Dental will provide a written response stating what it will pay for the service. (See "Predetermination of Benefits".)

Annual Benefit Maximum
The annual benefit maximum represents the total amount the plan will pay for each family member in a calendar year before you must begin paying 100% of the cost of your dental care.

Orthodontic treatment for children up to age 19 is subject to a separate calendar-year maximum and a lifetime maximum benefit for each covered person. In addition, the maximum paid by Delta Dental will be reduced by the amounts paid for orthodontic treatment by your previous dental care program, if any.

Emergency Care
The plan provides coverage if you or a covered dependent needs emergency dental care. The plan will reimburse you up to 100% per visit for emergency treatment when you see a Delta dentist and 80% per visit when you use a non-Delta dentist, up to the plan-year benefit maximum. Emergency treatment should be used for temporary relief of pain only. If additional dental care is required, you should receive routine dental services instead of relying on emergency care.

When you access emergency care, your dentist must provide a description of the nature of the emergency and the treatment provided.