SECTION SIX: Dental Benefits
teeth and gums are important to your well being. That's why the Plan
provides 100% coverage for preventive and diagnostic dental treatment
when you visit a participating Delta Dental provider. Dental benefits
are not covered as part of your UnitedHealthcare’s Choice
- You do not have to meet a deductible to receive dental
- The Delta Dental network gives you the freedom to choose
a dentist in or out of the network and still receive benefits.
- You and your eligible dependents are covered at 50% of
the allowance for Orthodontia, up to a lifetime maximum of
$2,000 or $2,500 EBL per covered person.
What You Need To Do:
- To get the most value for yourself and the Fund, find a dentist who
participates in the network. You may contact the Fund Office, or log
on to the Delta Dental website at www.deltadentalri.com to find a Delta
Dental provider near you.
- Show your Delta Dental ID card at the time of your appointment to
receive the discounted rate for services.
Your dental program is administered by Delta Dental's nationwide Premier
program. That means you have access to the largest dental network in
the country — more than 133,000 dentists participate in all 50
states. Dentists who belong to one of DeltaUSA's networks agree to
a negotiated fee for services and handle all claim filings and paperwork
Your benefits are paid according to an allowance — a pre-negotiated
rate for services. When you receive treatment from a participating Delta
Dental provider, the provider accepts the allowance as payment in full.
You are only responsible for your coinsurance, if any applies.
Your Dental Benefits At A Glance
Includes one oral exam per calendar year, two cleanings per calendar
year, x-rays and fillings
100% of the allowance
Includes extractions and root canals
100% of the allowance
80% of the allowance
80% of the allowance
50% of the allowance to a lifetime maximum of $3,500
Includes bridges and partial and complete dentures
80% of the allowance
50% of the allowance to a lifetime maximum of $2,000
or $2,500 for the Enhanced Benefit Level.
Annual Maximum Dental Benefit
The Plan will pay up to $2,000 or $2,500 for Enhaned
Benefit Level per covered person per year.
Of course, you are free to visit any dentist you'd like, even one that
does not participate in the network. If you receive dental care from
an out-of-network provider, you may have to pay the entire cost at
the time you receive services, and you may have to file your own claim
form to receive reimbursement. Ask the dentist to complete a standard
American Dental Association claim form and mail it to:
Delta Dental of Rhode Island
P.O. Box 1517
Providence, RI 02901-1517
|Filing Your Claims
Dental claims must be filed within one year of the
date of service in order to be considered for payment.
will have to pay any amount that the dentist charges above the allowance
amount. In other words, the Plan will only reimburse you for the amount
that a Delta Dental provider would have charged.
For Example: Jim needs to have some dental work done. The chart below
shows Jim's out-of-pocket expenses if he uses a Delta Dental provider,
or a provider who does not participate in the network.
Delta Dental Dentist
The Plan pays 100% of the allowance for the treatment
Jim needs. The Plan has negotiated with Delta Dental for a rate
of $200 for these services.
The Plan Pays 100% of the allowance for Jim's treatment.
Jim's out-of-network provider charges $250 for these services.
The Plan pays the entire cost of $200.
Plan pays 100% of the allowance, or $200. Jim must pay the difference
between the out-of-network rate and the allowance — $50.
The Delta Dental dentist files Jim's claim forms.
Jim may need to file his own claim forms.
Jim's out-of-pocket costs
If you have an urgent dental condition, you should seek treatment at
the nearest dentist's office, regardless of whether the dentist participates
in the Delta Dental network. You do not need prior approval before
seeking treatment, however, if you seek care from a non-network dentist,
Delta Dental will only pay for covered benefits, up to the allowance.
You will be responsible for any amount the provider charges above the
Delta Dental allowance.
If your dentist recommends treatment that is expected to cost $300 or
more, it is recommended that your dentist file a pre-treatment estimate
with Delta Dental for review. Delta Dental will determine how much of
the treatment will be covered under the Plan so that you will know your
out-of-pocket costs in advance.
What's Not Covered
The Plan does not cover dental services:
- If services do not qualify for payment under the Plan according to
Delta Dental's guidelines. A service may not qualify for coverage under
these guidelines even though it was furnished or recommended by a dentist.
- Unless specifically covered in the Plan's Certificate of Coverage.
- Received from a dental or medical department maintained by or on
behalf of an employer, a mutual benefit association, labor union, trustee
or similar person or group.
- For an illness or injury that Delta Dental determines arose out of
and in the course of employment.
- For which you are not required to pay, or for which you would not
be required to pay if you did not have Delta Dental coverage.
- For an illness, injury or dental condition for which benefits in
one form or another are available, in whole or in part, thorough a
government program or would have been available if you did not have
coverage through Delta Dental.
- Rendered by someone other than a licensed dentist or a licensed hygienist
if operating as authorized by applicable law.
- For consultations.
- For specialty oral exams (exams provided by endodontists, periodontists,
oral surgeons, orthodontists or prosthodontists),
- To treat temporomandibular joints (TMJ);
- To increase the height of teeth (vertical dimension) or restore occlusion.
- For restorations for reason other than decay or fracture, such as
erosion, abrasion or attrition.
- That are meant primarily to change or improve your appearance.
- For occlusal guards and splints.
- For bone grafts and transplants.
- To stabilize teeth when required due to disease such as periodontal
- For any lab exams or reports.
- For temporary, complete dentures and temporary, fixed bridges or
- Related to congenital anomalies other than for orthodontic services
that may be covered by the Plan's orthodontic rider.
- For prescription drugs.
- For general anesthesia for non-surgical extractions, diagnostic,
preventive or minor restorative services, including anesthesiologist
- For more than one crown on the same tooth; partial or complete denture
in the same arch or more than one fixed bridge in the same arch, space
maintainers or orthodontic appliance in a five-year period.
Delta Dental also reserves the right to adopt and to apply administrative
policies when reasonable in approving the eligibility of members and
the appropriateness of treatment plans and related charges.