Dental Product Guide · Dental Product Guide Dental insurance for employers with 2 to 49 enrollees ... where there are a lot of Delta Dental PPO dentists. Employers where employees

Dental Product GuideDental Product GuideDental insurance for employers with 2 to 49 enrollees

Wisconsin’s No. 1 Dental Plan for more than 50 Years.

Now available!

TWO-YEAR RATE

GUARANTEES

*New business

only (5-49)

*

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— and learn how their dedication and expertise have madeDelta Dental Wisconsin’s No. 1 choice for dental benefits.

www.deltadentalwi.com

Meet the people ofDelta Dental of Wisconsin

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Our dedication to – and belief in – the small-business market is stronger than ever. Despite the challenges posed by the Affordable Care Act, smaller employers have realized the value of dental benefits, and are taking steps to ensure that dental benefits are a part of their organization’s overall benefit picture.

Delta Dental can help organizations complete that picture. All of our plans – every one – work with the ACA. You don’t have to bundle medical and dental coverage. You can have the Delta Dental plan and coverage you want and have it work with the ACA. We can make it happen.

If there’s one overriding theme to the recent changes in the healthcare landscape, it’s this: Healthcare is about making choices, so choose wisely. Delta Dental has the products, but more importantly, Delta Dental has the people to help you make the right healthcare choices for your business – choices that ideally include powerful, affordable, and health-enhancing dental benefits, backed by the top service team in the business.

Call us. We’re here to help.

Dave PetersonVice President, Sales and Marketing

SHOWN AT LEFT (front to back): David Peterson (Vice President, Sales and Marketing), Denny Peterson (Executive Vice President), Michelle Czaplinski (Director, Underwriting), Tom Williams (Sales, Northern and Western Wisconsin), Maureen Noteboom (Director, Account Management), Jenny Wydeven (Account Management, Madison), Rick Zupan (Manager, Sales, Statewide), Jackie Bloomer (Sales, Fox Valley, Madison, Milwaukee and Southeastern Wisconsin)

SMALL-GROUP TEAM NOT SHOWN: Becki Giese (Account Management, Fox Valley), Andy Wavrunek (Sales Support, Statewide), Megan Wolff (Sales Support, Statewide), Tracy Thiel (Account Management, Milwaukee and Southeastern Wisconsin), Lynn Horn (Account Management, Milwaukee and Southeastern Wisconsin), Michele Knoll (Account Management, Northern and Western Wisconsin)

The more things change ... the better we look.The more things change ... the better we look.

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The things you value most are the things we do best.The things you value most are the things we do best.

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What makes us different makes us better.

Service: OurS iS better.

It’s fast, local, and expert. Our Benefit Center was just named North America’s No. 1 Call Center.* A real person talks to you in 25 seconds or less, and we answer your questions on that first call 99 percent of the time. What other dental-insurance company can say that?

SavingS: we deliver mOre.

Delta Dental offers more ways to save. Our premiums are affordable, our plans reward people for taking care of their teeth, and they save members the hassle of filling out claim forms. And our Delta Dental PPO dentists save employees money on procedures fromcleanings to crowns.

netwOrkS: OurS are bigger.

Delta Dental has Wisconsin’s largest dentist networks. More than 90 percent of Wisconsin dentists belong to a Delta Dental network. When members ask, “Is my dentist in the network?” we make it easy to say yes! Our Delta Dental Premier network saves employees money even if a dentist isn’t part of our Delta Dental PPO network.

wellneSS: we imprOve health.

Delta Dental works with existing employee-wellness programs on simple ways to use dental benefits to make entire families healthier.

philanthrOpy: we take care Of wiScOnSin.

One of the best things about Delta Dental is that we’re not-for-profit. We are committed to giving back to the communities we serve, as we’ve been doing for the last 50 years. We try to ensure everyone in Wisconsin has access to quality oral healthcare.

reSearch: we SuppOrt it, and we put it tO wOrk.

Delta Dental supports research that could end tooth decay. That could save millions of dollars in healthcare costs – and make future generations healthier.

PICTURED ABOVE: Rick Zupan (Manager, Sales, Statewide) andJackie Bloomer (Sales, Fox Valley, Madison, Milwaukee and Southeastern Wisconsin)

*Awarded by Benchmark Portal at Purdue University to call centers with fewer than 100 agents.

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The Delta Dental PPO Plus Premier UltraSavings Plan delivers an affordable-yet-ample benefit for members who see a Delta Dental PPO dentist from the state’s largest PPO dentist network*.

what is the ultraSavings plan?The UltraSavings Plan combines an innovative in-network PPO benefit with an out-of-network benefit that encourages members to see a Delta Dental PPO dentist, while still covering their basic dental needs.

what else is included?Each UltraSavings Plan includes:

CheckUp Plus™: Diagnostic and preventive services don’t count against a member’s annual maximum with CheckUp Plus.

Evidence-Based Integrated Care Plan (EBICP): The industry-leading benefit enhancement for whole-body health, EBICP covers additional cleanings for pregnant women, diabetics, and people with other health conditions. See www.deltadentalwi.com/your-health/medical-conditions for more information.

mac plan OptionIn addition to choice of annual maximum and deductible, a MAC (Maximum Allowable Charge) plan option is available, but not required. With a MAC plan, members pay a lower rate, but out-of-pocket expenses can be higher when they see a dentist other than a Delta Dental PPO dentist.

how does this plan work with the affordable care act? The UltraSavings Plan is a comprehensive alternative to pediatric dental plans created to complywith the ACA.

*Delta Dental PPO network measured by access points.

Savings that really stack up!

dElta dEntal PPo PlUs PrEmIEr

a PPo plan that lives up to its name.

UltraSavings Plan

who is the ultraSavings plan for?

Employers looking forimmediate and long-term savings.

Employers located in areas where there are a lot of Delta Dental PPO dentists.

Employers where employees pay some or all of the premium.

this plan is best for:

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See a Delta Dental ppO dentist

Deductible Options – Individual/Family $25/$75 $50/$150

Individual Annual MaximumThe UltraSavings Plan includes CheckUp Plus™. With CheckUp Plus, benefits paid for diagnostic and preventive services do not apply to the individual annual maximum.

$1,000 $750

Diagnostic & Preventive ServicesExaminations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays once every five years. One-time application of sealants. Space maintainers as needed.

100%

80%*

Basic Restorative Services – Type 1 Emergency treatment to relieve pain, fillings.

80%*

50%*

Basic Restorative Services – Type 2Simple extractions.

50%*

40%*

Major Restorative Services Endodontics and periodontics (root canals and gum-disease treatment), oral surgery, crowns, complete and partial dentures, implants, fixed bridges, repairs and adjustments.

50%*

40%*

Orthodontic Services (Optional)If the group has 10 or more enrolled employees, it may choose to include orthodontic coverage. Coverage applies for dependent children to age 19. Orthodontic coverage is not available for groups under 10.

50%*

50%*

Lifetime Orthodontic Maximum $1,000 $750

Evidence-Based Integrated Care Plan (EBICP)Delta Dental’s Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases and medical conditions that have oral-health implications. These benefits address the unique oral-health challenges faced by persons with these conditions, and can play an important role in the management of an individual’s medical condition.

Included

Included

Dependent Age LimitationDependents covered to age 26, except as noted

for orthodontics

Dependents covered to age 26, except as noted

for orthodontics

Vision-Care Discount Program See page 16 for details.

Included Included

*Deductible applies.

see a delta dental Premier or any other

dentist

a PPo plan that lives up to its name.

delta dental ppO plus premierultraSavings plan

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The Delta Dental PPO Plus Premier Savings Planemploys the state’s largest dental PPO network*. Members enjoy a full in-network benefit if they seea Delta Dental PPO dentist, and fee ceilings andtreatment guarantees if they see a Delta DentalPremier network dentist.

what is the Savings plan?A savings PPO offers an in-network benefit that’s better than the out-of-network benefit, encouraging members to see a Delta Dental PPO dentist.

what else is included?Each Savings Plan includes:



mac plan OptionIn addition to choice of annual maximum anddeductible, a MAC (Maximum Allowable Charge) plan option is available, but not required. With a MAC plan, members pay a lower rate, but out-of-pocket expenses can be higher when they see a dentist other than a Delta Dental PPO dentist.

what plans are Similarly priced?For roughly the same price† you can choose:A Passive Plan with a lower annual maximum and/ora higher deductible (see page 10).

how does this plan work with the affordable care act? The Savings Plan is a comprehensive alternativeto pediatric dental plans created to complywith the ACA.

*Delta Dental PPO network measured by access points. | †As a standard $1,000 annual maximum, $50 deductible plan.


saving is simple – when members see a delta dental PPo dentist.

Savings Plan

who is the Savings plan for?

Employers looking forimmediate and long-term savings.


Employers where employees pay some or all of the premium.


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see a delta dental ppO dentist


dentist

Deductible Options – Individual/Family $25/$75$50/$150$75/$225

$25/$75$50/$150$75/$225

Individual Annual MaximumThe Savings Plan includes CheckUp Plus™. With CheckUp Plus, benefits paid for diagnostic and preventive services do not apply to the individual annual maximum.

$1,000$1,500$2,000

$1,000$1,500$2,000


100% 100%

Basic Restorative ServicesEmergency treatment to relieve pain, fillings, simple extractions.

80%* 60%*

Major Restorative Services Endodontics and periodontics (root canals and gum-disease treatment), oral surgery, crowns, complete and partial dentures, implants, fixed bridges, repairs and adjustments. Note: Groups may upgrade oral surgery, endodontic, and periodontic coverage to the basic-restorative-services level.

50%* 50%*


50%*

50%*

Lifetime Orthodontic Maximum$1,000$1,500$2,000

$1,000$1,500$2,000

Evidence-Based Integrated Care Plan (EBICP)Delta Dental's Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases and medical conditions that have oral-health implications. These benefits address the unique oral-health challenges faced by persons with these conditions, and can play an important role in the management of an individual's medical condition.

Included Included


for orthodontics


for orthodontics

Vision-Care Discount ProgramSee page 16 for details. Included Included

saving is simple – when members see a delta dental PPo dentist.

delta dental ppO plus premierSavings plan

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The Delta Dental PPO Plus Premier Passive Plan is the only passive PPO available in Wisconsin that offers the combination of significant cost savings from the state’s largest dental PPO network* and fee ceilings and treatment guarantees if members see a Delta Dental Premier network dentist.

what is the passive plan?The Passive Plan offers the same annual maximum, deductibles and coinsurance whether members see a Delta Dental PPO dentist, a Delta Dental Premier dentist, or a non-network dentist.

what else is included?Each Passive Plan includes:




what plans are Similarly priced?For roughly the same price† you can choose:A Savings Plan with a higher annual maximum and/or a lower deductible (see page 8); or an Enhanced Plan with a lower annual maximum and/or a higher deductible (see page 12).

how does this plan work with the affordable care act? The Passive Plan is a comprehensive alternativeto pediatric dental plans created to complywith the ACA.



Exactly the same benefits, in- and out-of-network.

Passive Plan

who is the passive plan for?

Employers looking to maximize dentist choice without penalties for seeing out-of-network dentists.

Employers located in areas where there are not a lot of Delta Dental PPO dentists.

Employers with employees scattered around the state or country.


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see a delta dental

Premier or any other dentist


$25/$75$50/$150$75/$225

Individual Annual MaximumThe Passive Plan includes CheckUp Plus™. With CheckUp Plus, benefits paid for diagnostic and preventive services do not apply to the individual annual maximum.

$1,000$1,500$2,000

$1,000$1,500$2,000


100% 100%


80%* 80%*


50%* 50%*


50%* 50%*


$1,000$1,500$2,000


Included Included


for orthodontics


for orthodontics

Vision-Care Discount Program See page 16 for details. Included Included


Exactly the same benefits, in- and out-of-network.

delta dental ppO plus premierpassive plan

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who is the enhanced plan for?

Employers looking to reward employees for seeing Delta Dental PPO dentists.




Looking for a better benefit? The Delta Dental PPO Plus Premier Enhanced Plan delivers top-of-the-line benefits when members see a PPO provider from the state’s largest dentist network*.

what is an enhanced plan?An Enhanced Plan offers a higher benefit when members see a Delta Dental PPO dentist and a standard benefit when members see a Delta Dental Premierdentist or a non-network dentist.

what else is included?Each Enhanced Plan includes:




what plans are Similarly priced?For roughly the same price† you can choose:A Passive Plan with a higher annual maximum and/or a lower deductible (see page 10).

how does this plan work with the affordable care act? The Enhanced Plan is a comprehensive alternativeto pediatric dental plans created to complywith the ACA.


Our richest small-employer benefit.

Enhanced Plan

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dentist


$25/$75$50/$150$75/$225

Individual Annual MaximumThe Enhanced Plan includes CheckUp Plus™. With CheckUp Plus, benefits paid for diagnostic and preventive services do not apply to the individual annual maximum.

$1,000$1,500$2,000

$1,000$1,500$2,000


100% 100%


90%* 80%*


60%* 50%*


50%* 50%*


$1,000$1,500$2,000

Evidence-Based Integrated Care Plan (EBICP)Delta Dental’s Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases and medical conditions that have oral-health implications. These benefits address the unique oral-health challenges faced by persons with these conditions, and can play an important role in the management of an individual’s medical condition.

Included Included


for orthodontics


for orthodontics

Vision-Care Discount Program See page 16 for details. Included Included



Our richest small-employer benefit.

delta dental ppO plus premierenhanced plan

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Delta Dental has great dental-benefits options for Wisconsin’s smallest employers. Our 2-4-enrolled plans reward employers for using Delta Dental’s sizable PPO network, and includes customer service delivered by North America’s No. 1 call center.

what else is included?Each 2-4 enrolled plan includes:



waiting periodsFor groups with an existing dental plan, there are no waiting periods for those enrolling during the initial enrollment period.

Waiting periods apply for groups with no existing dental plan, and for enrollees who waive coverage initially, drop coverage, or who become eligible for the plan after the initial enrollment period (new hires or qualifying events). There is a six-month waiting period for endodontics (root canals), periodontics (gum-disease treatment), extractions, and oral surgery, and a 12-month waiting period for crowns, implants, complete and partial dentures, fixed bridges, and repairs and adjustments. There is no benefit waiting period for diagnostic and preventive services, or basic restorative services.

how does this plan work with the affordable care act? Our 2-4-enrolled plans are a comprehensivealternative to pediatric dental plans created tocomply with the ACA.

The harder you look,the more savings you find.


We understand the need to watch every penny.

2-4-Enrolled Delta Dental Plans

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We understand the need to watch every penny.2-4 Premier Plus PPO 2-4 Advantage PPO

see a delta dental PPo dentist


dentist

see a delta dental PPo dentist


dentist

Deductible Options – Individual/Family $50/$150 $25/$75 $50/$150

Individual Annual MaximumDelta Dental 2-4 plans include CheckUp Plus™. With CheckUp Plus, benefits paid for diagnostic andpreventive services do not apply to the individualannual maximum.

$1,000 $1,000

Diagnostic & Preventive Services

Examinations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays once every five years. One-time application of sealants. Space maintainers as needed.

100%* 100%* 100% 80%*

Basic Restorative ServicesEmergency treatment to relieve pain, fillings.

80%* 80%* 80%* 70%*

Major Restorative Services

Endodontics and periodontics (root canals and gum-disease treatment), extractions and oral surgery, crowns, complete and partial dentures, implants, fixed bridges, repairs and adjustments.

50%* 50%* 50%* 40%*

Orthodontic Services Not Covered Not Covered


Included Included

Dependent Age LimitationDependents covered to

age 26, except as noted for orthodontics


for orthodontics

Vision-Care Discount ProgramSee page 16 for details.

Included Included

delta dental ppO plus premier2-4-enrolled dental plans


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Delta Dental of Wisconsin small-employer plans come with a money-saving Vision Care Discount Program at no additional cost.

Through our partnership with EyeMed Vision Care®, members save on eyewear, contacts, exams, even laser vision correction. EyeMed serves more than 140 million people and has a vast network of vision providers.

the discount program features:• Overall savings up to 35 percent

• Access to thousands of private practice and retail providers nationwide, including LensCrafters®, Target Optical®, Sears Optical®, Shopko® Optical and Pearle Vision®

• Choice of any product, including designer frames

• Savings on laser vision correction

• Replacement contact lenses by mail

additional notes:• Replacement contact lenses may be obtained online. Details are available at

www.eyemedvisioncare.com/deltadental

• Members receive a 20 percent discount on items not included under the program, when these

items are purchased at participating providers

• Retail prices may vary by location

program exclusions:• Orthoptic or vision training, subnormal vision aids,

and associated supplemental testing

• Medical and/or surgical treatment of the eye, eyes, or supporting structures

• Corrective and safety eyewear

• Services provided as a result of any workers’ compensation law

• Plano nonprescription lenses and nonprescription sunglasses (20 percent discount)

valUE-addEd sErvICEs

Great savings that are easy to see.

Vision Discount Program

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Member Benefit

Exam with Dilation as Necessary$5 off comprehensive

exam/$10 off contact-lens exam

Complete Pair Glasses PurchasedThe following discounts and fees for frames, lenses and lens options apply only if a complete pair is purchased in the same transaction. Items purchased separately will be discounted 20% off of the retail price.

Frames: Any frame available at provider location 30% off retail price

Single Plastic Lenses Including Standard Scratch Coating

Single-VisionBifocalTrifocal

Member Pays

$75$95$125

Lens Option

UV CoatingTint (solid and gradient)Standard PolycarbonateStandard Anti-Reflective CoatingStandard Progressive (add-on to bifocal)

Member Pays

$15$15$40$45$70

Conventional Contact Lenses: Applied to materials only 15% off retail price

Laser Vision Correction: LASIK or PRK 15% off retail price or 5% off promotional price

Frequency: Exams, frames, lenses, and contact lenses Unlimited

vision discount program

Great savings that are easy to see.

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ExclusionsDelta Dental small-employer plans do not cover the following (see employer contract or handbooks for definitions of terms used in this section):

1. Dental procedures provided or commenced prior to the effective date of the subscriber’s or covered dependent’s coverage under this contract.2. Dental procedures to treat injuries or conditions compensable under workers’ compensation or employers’ liability laws.3. Prescription drugs and pre-medications.4. Preventive control programs.5. Charges for completion of forms.6. Charges for consultation.7. Charges by any hospital or other surgical or treatment facility, or any additional fees charged by a dentist for treatment in any such facility.8. Charges for treatment of, or services related to, temporomandibular joint dysfunction.9. Services that are determined to be partially or wholly cosmetic in nature.10. Cast restorations placed on covered dependents under age 12.11. Prosthetics placed on covered dependents under age 16.12. Appliances, restorations, or procedures for: (a) increasing vertical dimension; (b) restoring occlusion; (c) correcting harmful habits; (d) replacing tooth structure lost by attrition; (e) correcting congenital or developmental malformations except in newly born children; (f) temporary dental procedures; (g) splints, unless necessary as a result of accidental injury.13. Dental procedures provided by other than a dentist or licensed hygienist employed by a dentist.14. Dental procedures to treat injuries or diseases caused by riots or any form of civil disobedience.15. Dental procedures to treat injuries sustained while committing a criminal act.16. Dental procedures to treat injuries intentionally inflicted.17. Replacement of lost or stolen dentures or charges for duplicate dentures.18. Dental procedures in cases for which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained.19. Local anesthetic is covered as a part of a dental procedure. General anesthetic or intravenous sedation is a benefit only when billed with covered oral surgery (cutting procedures).20. Procedures not specifically covered under this contract.21. If orthodontic procedures are included as benefits under your group’s contract, the repair and replacement of orthodontic appliances are not covered.

LimitationsCoverage for some services under the plan is subject to frequency and age limitations. These limitations and restrictions are described in the handbook and group contract. Copies of these materials are available by calling Delta Dental of Wisconsin at 800-236-3713.

Requirements and considerations

for all delta dental small-group plans• The plan must be sponsored by the employer. The employer will collect premiums via payroll deduction.

• A clear employer-employee relationship must exist.

• Employment must be full-time, year-round and not experience seasonal layoffs.

• The business has not been cancelled by another dental carrier within the past 36 months.

• Benefit accumulation period is calendar year.

• Subscribers may use the national Delta Dental Premier and Delta Dental PPO dentist networks.

• Retirees are not eligible unless all active employees are eligible for the plan.

• In order to enroll dependents, the employee must be enrolled.

• Only group-billing format is available; no individual billings can be accommodated. Individual COBRA billings are not available.

• The patient’s coinsurance is based on the applicable percentage of the dentist’s billed fee or the maximum plan allowance, whichever is less

• All contracted services are available to the Covered Person upon the date of eligibility. Note: Benefit waiting periods may apply.

• For employers offering open enrollment, an employee who waived coverage or dropped coverage may enroll only during the open enrollment period. Waiting periods may apply.

• Participation is based on enrollment of all eligible employees except those who submit waiver cards indicating that they have coverage under their spouse’s plan. Waiver forms are required for all employer-contributory plans.

• Delta Dental small-employer plans include coverage for teeth lost prior to the effective date, and pre-existing conditions.

Underwriting GuidelinesGroup acceptance is not guaranteed. approval of coverage

is contingent upon underwriting acceptance.

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Accounting, Auditing, & Bookkeeping

Advertising

Agricultural Production – Crops

Agricultural Production – Livestock & Animal Specialties

Attorneys & Legal Services

Automotive Dealers, New & Used

Beauty/Barber Shops

Boat Dealers

Bowling Alleys

Business & Professional Organizations

Churches

Dentist Offices

Eating & Drinking Places

Engineering & Architectural Services

Gas Stations, Convenience Stores

Holding & Other Investment Offices

Home Healthcare

Hospitals, Medical & Dental Labs

Hotels, Motels, Campgrounds

Insurance Agents, Brokers, & Service

Insurance Carriers

Labor, Political, Civic & Social Organizations

Local & Suburban Transit & Interurban Hwy. Passenger Trans.

Management & Public Relations

Medical Service & Health Insurance

Mobile-Home Dealers

Motorcycle Dealers

Movie Theaters

Personal Services

Physician, Other Healthcare Offices

Real Estate Brokers

Recreation & Utility-Trailer Dealers

Research & Testing Services

Schools, Including Colleges & Universities

Security & Commodity Brokers, Dealers, Exchanges, & Services

Subdividers & Developers

Transportation Services

Travel Agents/Tour Operators

Unclassified Health Services

Unclassified Membership Organizations

Unclassified Services

Stevens Point Office

P.O. Box 828Stevens Point, WI 54481800-236-3713 (toll-free)Fax 715-343-7623

Milwaukee Office

1233 North Mayfair Road Suite 204Milwaukee, WI 53226888-456-2711 (toll-free)Fax 414-607-6088

Madison Office

725 Heartland Trail Suite 205Madison, WI 53717877-577-7449 (toll-free)Fax 608-831-9384

• A Delta Dental small-employer plan must be the only dental plan offered.

• Rates are guaranteed for 12 or 24 months from the effective date of coverage, depending on the plan chosen.

for 2-4-enrolled plans only• The total number of eligible employees and dependents participating must be equal to or greater than the percentage of the employer contribution. Example: With an employer contribution of 75 percent, a minimum of 75 percent of eligible employees must participate.

Special requirements for passive, enhanced, Savings, and ultraSavings plans

• Delta Dental small-employer plans are open to groups with 5-49 enrolled employees.

• Orthodontic coverage is available only to groups of 10 or more enrolled employees.

• If orthodontic coverage is purchased, all families must accept the orthodontic benefit with the same maximum.

Special requirements for 2-4 plans• The 2-4-enrolled plans are open to groups with 2-4 enrolled employees.

• Two-person groups may not consist of enrollees residing at the same address.

• A company wage and tax statement must accompany the group application.

rate adjustmentsThe types of businesses listed at right are eligible for the program if they meet other underwriting guidelines, but require an 18 percent adjustment on the standard rates. This list is not all-inclusive. If you are uncertain about the industry type and whether a rate adjustment would apply, contact the sales department. See below for complete contact information.

BR213-1309

Documents

Dental Product Guide · Dental Product Guide Dental insurance for employers with 2 to 49 enrollees ... where there are a lot of Delta Dental PPO dentists. Employers where employees