UMass Worcester - GSBS Students
Delta Dental Plan Options
Frequently Asked Questions:
Which Dental Plan is Right for Me?
The two plans offered to you are very different. As with any insurance plan, please make sure that you review the Plan Highlights & Benefit Summary before enrolling.
The information below is intended to help you understand some frequently asked questions, but it is still important for you to review the Plan Highlights & Benefit Summary in full before enrolling in either plan.
Is there a maximum benefit?
- DeltaCare: There is a $1,000 calendar year maximum (January-December) benefit per member for certain specialty services (endodontic services, periodontic services, and oral surgery). There is no maximum benefit for other covered services outlined in the plan summary. The frequency of certain services, however, is limited. Please refer to the frequency limitations and exclusions sections of the plan summary for details on those limitations.
- PPO Plus Premier: There is a $1,000 calendar year maximum (January-December) benefit per member. This maximum applies to all covered services on the plan summary. The frequency of certain services is also limited. Please refer to the frequency limitations outlined in the benefit summary: Example Teeth Cleaning-Once every six months.
How do I find a participating dentist?
- Delta Dental has a variety of networks. Do not assume that because a dentist accepts "Delta Dental" that he/she is a contracted provider that accepts the Delta Dental Fees for services. Ask the providers office are they a “contracted dentist” under the dental network that you have chosen either the DeltaCare Network, or the PPO or Premier Networks. The two dental plans offered to you use different Delta Dental networks as described. You can search for participating providers here: http://www.deltadentalma.com to find a participating dentist in your area. Please be careful to select the correct Delta Dental network when searching the directory (DeltaCare, Delta Dental PPO or Premier Networks).
- DeltaCare: This plan uses the DeltaCare Provider Network only. When choosing a Primary Care Dentist (PCD) you MUST select one in the DeltaCare network. Dentists in the DeltaCare network are only located in Massachusetts. If you enter a dentist who does not accept the DeltaCare plan, your selection will be voided and Delta Dental will reassign you to a contracted dentist within the DeltaCare network based on your home address. Please note that you can change your DeltaCare Provider at any time by calling DeltaCare at 800-327-6277. Changes must be made no later (preferably earlier) 21st of the month to be effective on the 1st of the following month.
- Delta Dental PPO Plus Premier National Networks: This plan utilizes both the Delta Dental PPO and Premier National Networks. As a member you benefit from having access to two of Delta Dental’s extensive national networks:
- Delta Dental PPO, with more than 228,000 participating dentist locations you will enjoy the greatest out-of-pocket savings when visiting Delta Dental PPO Network dentists as part of the in-network services outlined in the plan summary at 100%, 80% and 50%.
- Delta Dental Premier, the largest dental network in the country with more than 314,000 dentist locations. You will receive good value from Delta Dental Premier Network dentist but will be subjected to the out-of-network coinsurance level shown on the plan summary at 80%, 60% and 30% for various dental services including an out-of-network deductible of $100 per person per Calendar Year.
- The Delta Dental PPO Plus Premier National Networks have participating providers nationwide and offer discounted fees. You do not need to select a primary care dentist under either network.
How much do I have to pay when I see a participating dentist?
DeltaCare: As a DeltaCare member, you are responsible for the co-payments listed in the benefit summary when you receive care from a DeltaCare primary dentist or a specialist: Ex: Minor Restorative Services Procedure Code D2140 One surface silver filling $35.00. All payments should be made directly to the treating dentist. Most Preventive and Diagnostic services are covered at 100% without any co-payment. The co-payment schedule can be found on www.universityhealthplans.com at any time during the policy year.
PPO Plus Premier: Simply provide your dentist with the information that is printed on your ID card. The dentist will submit your claim and be paid directly by Delta Dental. If you have a patient responsibility, Delta Dental will send you an Explanation of Benefits (EOB) detailing what Delta Dental paid the dentist under your plan’s coverage and your remaining patient balance, which you pay directly to the dentist. You are responsible for any co-payments (see the plan summary for In and Out of Network benefits and deductibles (out of network only).
If you receive a treatment that is not covered under your plan, you may be billed at the dentist’s normal rate rather than Delta Dental’s contracted rate. Also, if you receive a treatment after you have exhausted your calendar year maximum ( $1,000) or if you receive a treatment which will cause you to exceed your maximum, you may be billed at the dentist’s normal rate rather than Delta Dental’s contracted rate.
What happens if I see a non-participating dentist?
- DeltaCare: Out-of-Network Coverage
DeltaCare provides coverage for out-of-network services; however, the benefits are lower than the coverage members receive care from a DeltaCare dentist. This means greater out-of-pocket expense for you.
$100 deductible: Members who receive care from non-participating dentists must satisfy a $100 annual deductible that applies to all services.
Reduced benefits: Coverage for out-of-network services is 20% lower than the co- insurance for an in-network DeltaCare panel dentist.
Out-of-network benefits will be based on either the dentist’s charge or the maximum allowable fee for the service, whichever is lower.
Please refer to the plan summary section titled Out-of-Network Coverage.
- PPO Plus Premier: Your Delta Dental PPO Plus Premier Incented Voluntary Plan provides coverage for services received from dentists who don’t participate in the Delta Dental PPO or Delta Dental Premier networks. However, your out-of-pocket expenses may be more. Delta Dental’s payment for services received from non-participating dentists is based on either the dentist’s fee or the maximum plan allowance for non-participating dentists, whichever is lower. If you utilize the services of a non-participating dentist whose fees are higher than the maximum plan allowance, you will be responsible for the difference between Delta Dental’s payment and the dentist’s total submitted charges.
- The Claims Process for Non-Participating Dentists
Simply provide your dentist with the information that is printed on your ID card. Your dentist will collect his/her fees directly from you.
Delta Dental will reimburse you based on a claim form that you submit to: Delta Dental, P.O. Box 249, Thiensville, WI 53092.
You are responsible for paying any deductibles or co-payments as well as the difference between what Delta Dental pays and what the dentist charges.
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