Section 3: > How The Delta Preferred Option (DPO) Works > Close-up: Janet
Close-Up:
Janet
Janet tried to ignore it as long as she could. But now the toothache is beginning
to interrupt her work. Every time she sits down to write, the dull ache creeps
into her plot-lines, and it's not making for very interesting reading.
Janet just can't catch a break. On top of the toothache, when she calls her
dentist to make an appointment, she learns he's retiring. Since she needs to
find a new dentist anyway, Janet decides to try a DPO dentist, to take advantage
of the lower, negotiated rates.
Janet does her homework and chooses a dentist online using Delta Dental's website.
Finally, some good news - she calls the office and confirms that Dr. Cooper
is part of the DPO network and is accepting new patients. After examining the
tooth that has been bothering Janet, Dr. Cooper recommends a crown.
The following examples illustrate the cost difference between a Delta DPO dentist
and a non-Delta dentist*:
| WITH A DELTA DPO DENTIST |
| Charge for crown |
$175.00
|
| Janet's deductible |
- $ 75.00
$100.00
|
| Plan pays 80% of the remaining $100 |
- $ 80.00
|
| Janet pays 20% |
$ 20.00
|
| Janet's cost with a DPO dentist (deductible + her coinsurance) |
$ 95.00
|
|
| WITH A NON-DELTA DENTIST |
| Charge for crown |
$280.00
|
| Delta-approved fee for a crown (R&C) |
$175.00
|
| Janet's deductible |
- $ 75.00
$100.00
|
| Plan pays 70% of the remaining $100 |
- $ 70.00
|
| Janet pays 30% |
$ 30.00
|
| Plus the difference between non-Delta dentist submitted
fee and Delta-approved fee |
$105.00
|
Janet's cost with a non-Delta dentist
(deductible + amount over R&C + her coinsurance) |
$210.00
|
|
| JANET'S SAVINGS WITH A DELTA DPO DENTIST |
| Janet's cost with a non-Delta dentist |
$210.00
|
| Janet's cost with a DPO dentist |
- $ 95.00
|
| Janet's savings with a DPO dentist |
$115.00
|
|
Note: Costs cited in this example are for
illustrative purposes only. Your own costs may be different.
Predetermination Of Benefits
The plan has a feature called predetermination of benefits. It lets you know in
advance how much the plan will pay before your dentist actually begins the dental
work he/she is recommending. Predetermination of benefits allows you to have your
questions answered before you incur an expense and may help to prevent any misunderstanding
about your financial responsibilities.
You and your dentist should consider obtaining a predetermination of benefits
if total charges for the planned course of treatment are expected to be more
than $300 - or if extensive services, such as crowns or bridges, are being recommended.
While predetermination of benefits is recommended, it is not required.
Here's how predetermination of benefits works: When deciding on a treatment
plan, your dentist should submit an Attending Dentist's Statement to Delta Dental
specifying the proposed course of treatment. Delta Dental will send your dentist
a Notice of Predetermination, which estimates how much of the proposed charges
you'll have to pay.
Predetermination of benefits doesn't guarantee that benefits will be paid.
Actual benefits may differ from the estimated benefits, depending on:
- The actual services provided;
- The amount of the deductible;
- Whether you have met the plan-year benefit maximum; and
- Whether you're covered by more than one dental plan.
If you have any concerns about the predetermination of benefits, you may contact
Delta Dental before your treatment begins.
ALTERNATIVE BENEFIT PROVISION
If you or your dentist selects a treatment plan that's more expensive than the
treatment normally provided, you may be responsible for additional out-of-pocket
costs. The plan will pay the applicable percentage of the least expensive professionally
acceptable treatment plan. If you choose a more expensive treatment plan, you'll
be responsible for the remainder of the dentist's fee after the plan pays benefits.
For example, you choose a gold crown when one made of semi-precious metals
would restore the tooth just as well. Because you've chosen a more expensive
treatment, you would be responsible for the cost above and beyond what the plan
would pay for a crown made of semi-precious metals.
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