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YORK COUNTY SCHOOLS
Open Enrollment for Plan Year 2021
Delta Dental Benefit Plans
Delta Dental PPO Plus PremierTM
Access to all networks: Premier, PPO and out-of-network statewide and national
Delta Dental PPOTM – EPO Plan Design PPO dentist network only statewide and national
With York County School’s PPO Plus Premier plan option members have two networks to choose from (Premier, PPO and also out of network); the EPO option offers the PPO network only (no out of network);
Delta Dental Premier® – This is Delta Dental’s largest network and provides the greatest access to care.This network includes approximately 84% of Virginia dentists.
Delta Dental PPOSM – The PPO network provides our deepest discounts and the lowest out-of-pocket costs. 55% of Virginia dentists participate.
Members can go out-of-network in the PPO Plus Premier Plan only, but will receive the greatest savings when they choose a dentist that participates in one of our networks.
Out-of-Network-Freedom to go to
any licensed dentist -Highest out-of-pocket costs
$Delta Dental Premier
-Broadest network-Higher out-of-pocket
costs than PPO
$Delta Dental PPO-Narrower network
-Lowest out-of-pocket costs
$
How Delta Dental’s Networks Work
PPO NETWORK PREMIER NETWORK OUT-OF-NETWORK
Diagnostic and Preventive Services(cleaning, exam, fluoride, bitewings)
100% PPO Allowance
100%Premier Allowance
100% Non-Par Allowance
Basic Services(fillings, extractions, root canals, periodontics, oral surgery)
80% PPO Allowance
80%Premier Allowance
80%Non-Par Allowance
Major Services(crowns, dentures, bridges, Implants)
50% PPO Allowance
50%Premier Allowance
50%Non-Par Allowance
Orthodontic Services (for subscriber and covered dependents)
50% PPO Allowance
50%Premier Allowance
50%Non-Par Allowance
Annual Deductible $50/$150 $50/$150 $50/$150
MaximumsContract YearLifetime Orthodontic
$1,500$1,500
$1,500$1,500
$1,500$1500
Delta Dental PPO Plus Premier™Option 1
PPO NETWORK PREMIER NETWORK OUT-OF-NETWORK
Diagnostic and Preventive Services Fixed copay No Coverage No Coverage
Basic Services Fixed copay No Coverage No Coverage
Major Services (crowns, dentures, bridges) Fixed copay No Coverage No Coverage
Orthodontic Services (for subscriberand covered dependents) 50% No Coverage No Coverage
Annual Deductible None N/A N/A
MaximumsContract YearLifetime Orthodontic
$1,500$1,500 N/A N/A
Delta Dental PPO™ – EPO Plan DesignOption 2 (PPO Network Only)
PPO Plus Premier and EPO-PPO Benefit DifferencesP PPO Plus Premier
Option 1PPO – EPO PlanOption 2
Provider Network PPO, Premier and Out of Network PPO Network Only
Deductible $50 /$150 applies to Basic and Major Services Only No Deductible
Provider Payment Co-Insurance Fixed Copays based on Scheduleexcept for Orthodontics
Full-mouth X-rays (D&P) Once in 5 years Once in 3 years
White/composite fillings (Basic) On ALL teeth On front 6 teeth, upper and lower
Implants Covered in Major Services at 50% Not Covered
Prevention First Included Not Included
Periodontal Cleaning Twice in a Calendar Year in addition to two regular cleanings and oral exams
Twice in a Calendar Year – either a periodontal cleaning or a regular cleaning;
Lab Fees Included in cost of Crown, Denture, Bridge
Not included in fixed copay for Crown, Denture, Bridge
PPONetwork
PremierNetwork
Out-of-Network
Dentist Charge $215 $215 $215
Plan Allowance $126 $169 $152
Coinsurance Amount 80% 80% 80%
Delta Dental Payment $100.80 $135.20 $121.60
Patient Payment $25.20 $33.80 $93.40
*This example is for illustrative purposes only and assumes that the annual deductible has been met.
PPO Plus Premier Plan Payment Example*
PPO Network Premier Network Out-of-NetworkDentist Charge $215 $215 $215
Plan Allowance $126 $0 $0
Patient Copayment $25.20 0% 0%
Delta Dental Payment $100.80 $0 $0
Patient Payment $25.20 $215 $215
*This example is for illustrative purposes only.
Delta Dental PPO™ - EPO Plan Design Payment Example*
Prevention First – PPO Plus Premier Product Only
Diagnostic and Preventive Treatment (twice annually)
Delta DentalPays
MemberPays
MaximumRemaining
$190 $0 $1,310
With Prevention First
Diagnostic and Preventive Treatment (twice annually)
Delta DentalPays
MemberPays
MaximumRemaining
$190 $0 $1,500
Cleanings and preventive visits are covered at your plan’s current level…and the costs for these services will not count against your annual benefit maximum!
This means that you will always have benefits for these services, even if you have used all of your annual maximum benefit allowance. Here is an example* on how the Prevention First benefit works:
*Dentist charges may vary. Rates vary depending on your plan type.
Pre-Determination of Benefits
• Recommended – but not required• For services of $250+• Process:
– Dentist submits to Delta Dental to include proposed treatment plan– Delta Dental processes like a claim form (turnaround time 5-7 business days )– Statement mailed to dentist and subscriber – indicating reimbursement amount
Allows members to make an informed decision prior to having services rendered!
• You will receive two ID cards. At your first appointment, show your dentist your new ID card. If your dentist participates in our networks, your dentist will file your claims for you.
• If your dentist does not participate, you may have to pay your dentist upfront and file for reimbursement. Claim forms may be found at DeltaDentalVA.com.
• If you have questions, call customer service at 800-237-6060. Representatives are available:
- 8:15 am to 6:00 pm; Monday through Thursday- 8:15 am to 4:45 pm; Fridays
(Eastern Times noted)
Delta Dental PPOplus Premier
Group Name: Newport News Public Schools Number: XXXXXXSubscriber Name: John DoeIdentification No: 00000000000000Membership Type: FamilyEffective Date: 01/01/2021For Benefit Services: 800-237-6060
www.deltadentalva.com
After You Enroll
Check Out Our Website: DeltaDentalVA.com
No login necessary to:Find a dentist Website Tutorials
It’s Easy to Find a Network Dentist
From the home page scroll down to the Find a Dentist section.You can enter specialty, plan, distance and zip code to search for a participating provider in your area.
You do not need to log in to perform a dental search.
www.DeltaDentalVA.com
Secure Members Page:
• Replacement ID Cards
• View Your Benefits
• Cost Estimator Tool
• Claims Information
• Download forms
• Live Chat with Customer
Service
JOHN DOEABC COMPANY
00000712345-000000001-000000001
510000XXXXXXXX-01FAMILY
4 MEMBERS07/01/2020
JOSEPH R. SMITH DDS
123 APPLE LANESUFFOLK, VA 23435
YES/IN-NETWORKGET DIRECTIONS
757-123-4567
Mobile App
Members can log into the free Delta Dental mobile app using the same website login information. Once logged in:• Check coverage and review claims
information• View, print and email your ID card• Use our Cost Estimator Tool
QUESTIONS?
Benefit Services1-800-237-60608:15AM – 6:00 PM (Monday – Thursday)8:15AM – 4:45 PM EST (Friday)
The Delta Dental Difference®
Fulfilling our mission of providing affordable oral healthcare to all.
We are the dental experts.