Dental Plans. for Individuals, Families & Self Employed

Transcription

1 Dental Plans for Individuals, amilies & Self Employed Texas

2 Help e Choose A Plan When can I begin receiving dental care? Discount Plan - can begin receiving benefits and dental care the day they enroll. Co-Pay & Co-Insurance Plans - the policy and benefits become effective the 1st day of the month following the date we receive your enrollment. How do waiting periods affect my dental care? Discount Plan There are no waiting periods. Co-Pay & Co-Insurance Plans No waiting periods for preventive care (cleanings, oral exams, etc). Waiting periods do apply to basic and major services; however, even before waiting periods are met, members pay lower contracted fees for all covered services from in-network dental providers. What if my dental provider does not participate on a Dental Select network? Discount Plan No out-of-network discounts. ember must receive dental care from a Silver Network provider to receive discounts. Co-Pay Plans After deductibles and waiting periods are met, Co-Pay Plan members receiving dental care from a general dentist will receive an out-of-network benefit, which pays according to the Schedule of Co-Payments. Co-Insurance Plans After deductibles and waiting periods are met, all Co-Insurance Plans pay an out-ofnetwork benefit, according to the plan fee schedule. All charges over the plan payment will be the member s responsibility. Do I get benefits for orthodontia work? Discount, Co-Pay and Co-Insurance (Option 1) Plans rom the plan s effective date, all members receive a 2% discount on all covered orthodontic services when using an in-network dental provider. Co-Insurance (Option 2) Plans embers receive a 2% discount plus a 5% paid benefit (for children under 19) once the 24 month orthodontia waiting period is met, subject to plan maximums. Before the waiting period is met, all members receive a 2% discount on all covered orthodontic services when using an in-network dental provider. What if I require services from a dental specialist? ost general dentists will perform specialist services. In the event one is needed, specialists include Endodontists, Periodontists, Pediatric Dentists, Orthodontists, Prosthodontists, and Oral Surgeons. Discount Plan embers receive discounts on all services from in-network specialists. Co-Pay Plans embers receive a 2% discount on all services provided by an in-network specialist. No waiting periods or deductibles apply. Co-Insurance Plans After waiting periods and deductibles are met, members receive a paid benefit for covered services provided by both general dentists and specialists. In addition, you can save on out of pocket expenses when visiting an in-network provider. What if I need services before my waiting periods or deductibles are met? Even before waiting periods and deductibles are met, members receive lower contracted fees for all covered services from network providers. Three easy ways to enroll: Enroll online at 1. & waive the $15 enrollment fee, or call a Dental Select representative at ill out the attached enrollment form and return to Dental Select with your $15 enrollment fee included 3. Call your insurance agent

3 Over 2 years of experience providing dental insurance to individuals Guaranteed acceptance and renewal Dental insurance experts Community partner through the Sealants for Smiles program which applies sealants to over 4,7 underprivileged children each year Choice of Discount, Co-Pay & Co-Insurance Plans with a wide range of monthly premiums Why Dental Select? ast claims payment & accuracy Cosmetic discount available for bleaching, veneers, etc. Quality s (as of Oct. 1, 28) Silver over 1,8 providers Gold over 2,3 providers Platinum Co-Pay over 3, providers Platinum Co-Insurance over 6,4 providers Over 58, providers nationwide (Platinum Co-Insurance only) Value of Dental Insurance You are twice as likely to receive regular dental check-ups with dental insurance. or every $1 you spend in preventive dental care you could save $8 to $5 in restorative and emergency treatment. Regular dental check-ups along with healthy teeth and gums not only saves you money, but will also: ADA Code Reduce your risk of a heart attack up to 15% Reduce the risk of premature and low birth weight babies by 7% Decrease a woman s risk of developing gestational diabetes Significantly reduce complications associated with diabetes Decrease the most common chronic childhood disease tooth decay Ensure early detection and increase your chance of surviving oral cancer Description Dental Insurance = Healthier YOU Your Savings with Dental Select! Average Cost Discount Plan Co-pay Gold Plan (TX-3) Co-pay Platinum Plan (TX-3) Co- Insurance Gold Option 1 Co- Insurance Platinum Option 1 Co- Insurance Gold Option 2 Co- Insurance Platinum Option 2 D12 Routine Checkup $37. $15. $. $. $. $. $. $. D1 Adult Cleaning $73.51 $. $. $. $. $. $. $. D2 Child Cleaning $5.74 $3. $. $. $. $. $. $. D123 luoride (age 14 & under) $25.81 $7. $. $. $. $. $. $. D214 illing - 1 surface (silver) $6.83 $. $. $. $.8 $.7 $9.2 $.8 D2391 illing - 1 surface (white) $8.95 $69. $34. $34. $23.7 $25.8 $15.8 $.2 D275 Crown - porcelain $9.92 $482. $. $349. $255. $283.5 $255. $283.5 D333 olar Root Canal $ $38. $272. $392. $197. $28. $197. $28. D41 Periodontic Root Planing $19.64 $. $86. $99. $53. $64. $53. $64. D71 Extraction of Primary Tooth $9.15 $5. $. $. $.9 $2.7 $12.6 $.8 D721 Surgical Extraction $.97 $88. $6. $8. $3.3 $37.2 $2.2 $24.8 Average cost shown is based on the most heavily populated zip codes for contracted providers in Texas. Your payment is subject to waiting periods, deductibles & plan maximums. Savings based on services performed by a contracted provider.

4 Plan Summary of Benefits Discount Plan Co-Pay Plans Co-Insurance Plans Can I visit a non-contracted dental provider? No Yes - Only (Receive a 2% discount for contracted specialists, no other benefits apply) Yes When is my plan effective? Available the day you enroll 1st day of the following month from the date we receive your enrollment Who can I include on my plan? Spouse, Children, Grandchildren, Parents & Grandparents Spouse & any unmarried children up to age 25 Type of Plan Insured PPO Insured PPO ee-for-services discount plan Contracted or Non- contracted provider discount only Non- Option 1 Option 2 Preventive Up to 9% Cleanings (2 per year), exams, fluoride (14 & under) and x-rays 1% ee Reduction 1% 1% Basic Up to 6% Includes fillings and oral surgery ee Reduction ajor Up to 5% Includes crowns, bridges, periodontics, endodontics & dentures ee Reduction Refer to Partial Schedule of Up to 7% Coverage Co-Payments 7% 8% Up to 5% Coverage 5% 5% Deductible Per calendar year. aximum three per family Applies to all services $25/$75 $75/$225 $5/$15 aximum Benefit Applies to all services excluding orthodontics Per person, per calendar year Waiting Periods: Basic ajor Orthodontic No aximum No aximum 6 onths 12 onths $1, (of which $5 per year can be used for ajor Services) 6 onths onths 6 onths 15 onths Discount - Insured - 24 months Orthodontics Children & Adults 2% Discount () 2% Discount () No Coverage 2% Discount () Adults 2% Discount (Contracted) Children under19 5% Insured after 2% Discount (Contracted) Orthodontic aximum No aximum No aximum No aximum $5 per year $1, lifetime maximum Discount Vision included for your entire family on every plan Network Options Silver Gold Platinum Gold Platinum Gold Platinum onthly Rates Single $8 $15 $2 $ $22 $23 $3 Two Party $ $ $37 $ $4 $ $55 amily $15 $ $55 $ $55 $57 $74 The Discount Plan is not a dental insurance policy. This program provides discounts only from a certain network of dental providers. The member is responsible to pay for all services but will receive a discount from dental providers who are contracted on Dental Select s Silver Network. See Partial Benefits Schedule & Schedule of ember ees for details ACE USA is the U.S. domestic operating division of ACE Limited. Insurance products and services are provided by the U.S. insurance underwriting companies and not by ACE Limited. This plan of insurance is underwritten by ACE American Insurance Company. The benefits illustrated are in summary form only. They should not be construed as complete in and of themselves. They are for comparison and in case of discrepancy, the plan documents apply. Please refer to the plan certificate booklet for a complete description of benefits, limitations & exclusions.

5 Partial Schedule of Co-Payments Deductibles: Co-Pay Plans only (applies to all services) - $25 per person / $75 family maximum General Areas GOLD & PLATINU ONLY TX-1: San Antonio TX-2: Austin/Waco TX-3: Dallas / T. Worth, Houston, Corpus Christi, El Paso Co-payment schedules are based on your network provider s zip code. You will receive a complete list of co-payments with your ID card. Platinum Gold Silver* TX-1 TX-2 TX-3 TX-1 TX-2 TX-3 Code Procedure Description PREVENTIVE D12 Routine checkup D15 Comprehensive exam D21 X-rays, complete set D274 X-rays, 4 bitewings D33 X-rays, panoramic D1 Adult cleaning D2 Child cleaning D123 luoride (age 14 & under) Patient ee BASIC D51 Sealant - per tooth (age 14 & under) illings D215 Amalgam (silver) - 2 surface D23 Composite (white) - 2 surface anterior D2392 Composite (white) - 2 surface posterior Extractions D71 Extraction - Primary tooth D714 Extraction - Permanent tooth CROWNS D275 Crown - porcelain D5 Core build up ENDODONTICS (ROOT CANALS) D3 Bicuspid root canal D333 olar root canal PERIODONTICS D41 Periodontic root planing D491 Periodontic maintenance PROSTHODONTICS (DENTURES) D5 Complete denture - upper D512 Complete denture - lower ORAL SURGERY D721 Surgical extraction D723 Surgical extraction - impacted ISCELLANEOUS D999 OSHA infection and sterilization * Discount only This is not a complete list of procedures. You will receive the complete version with your plan ID card. Any procedure not listed in the complete version is available on a fee-for-service basis, no discount will apply. This sample of fees is valid through December,.

6 Access Discount Vision If you would like a simple and carefree vision plan with savings of up to 4% at more than 4, independent providers and retail stores such as LensCrafters, Pearle Vision, Sears Optical, and Target Optical, this is the vision plan for you. Your entire family can be included, as long as they are also on your dental plan. Access Vision eatures - No maximums - No waiting periods - No limits on number of visits - No claims to submit - No limits on amount of purchase - All styles, sizes and materials are included - Includes contact lenses - Receive a discount of 5-15% on laser vision correction surgery - Large nationwide panel of providers Summary of Vision Benefits Vision Care Services Exam with Dilation as Necessary:* ember Cost $5 off routine exam $1 off contact lens exam Complete Pair of Glasses Purchase: frame, lenses and lens options must be purchased in the same transaction to receive full discount. Standard Plastic Lenses: Single Vision Bifocal Trifocal Progressive rames: Any frame available at provider location Lens Options: UV Coating Tint (Solid & Gradient) Standard Scratch-Resistance Standard Polycarbonate Standard Anti-Reflective Coating Other Add-ons & Services Contact Lens aterials: (Discount applies to materials only) Disposable Conventional Laser Vision Correction: Lasik or PRK $5 $7 $15 $5 35% off retail price $15 $15 $15 $4 $45 2% Discount N/A 15% off retail price 15% off retail price -or- 5% off promotional price * Under contract, ACCESS Vision Providers may charge usual & customary rates for a comprehensive exam up to a contracted fee per region. Discount Vision included for your entire family on every plan The ACCESS Vision Plan is a fee for service discount plan, it is not an insured product. This program provides discounts only from a certain network of vision providers. The member is responsible to pay for all services but will receive a discount from vision providers who are contracted on the Access Network.

7 Annual & onthly Billing Options ONTHLY payments are taken via automatic withdrawal or charge from: 1. Checking or Savings account; or 2. Credit or Debit Card. (Visa or aster Card) Note: Premiums are drafted on the 16th of the month or the next 2 business days. On Co-Pay and Co-Insurance plans, premiums are paid one month in advance. or Discount plans, premiums are paid for the current month. When enrollments on Co-Pay or Co-Insurance plans are received after the 14th of the month, they will be charged for two months of premium (one for the month that the enrollment became effective and one for the month following) on the 16th of the month or the next business day; thereafter, they will be drafted for just one month. ANNUAL Payments can be made by: 1. Annual Check 2. Credit Card Payment (Visa or aster Card) Note: if annual payment is made by credit card, upon yearly renewal we will automatically charge the credit card 2 weeks in advance of the annual renewal date, unless a check is received before this time. At renewal, you can change to a monthly payment option. How do I cancel? All cancelation requests must be received in writing. Your cancelation will be effective the first day of the month following the month your written request is received. Dental Plan Exclusions No benefits will be paid: 1. for services and supplies not listed in the Coverage Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental. 2. for services provided by Specialists whether Contracted or. (Co-pay plans only) 3. for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons. 4. for services related to, performed in conjunction with, or resulting from a non-covered procedure. 5. for charges in excess of the contracted ee-for-service schedule or the Reasonable and Customary rate, whichever applies. 6. for any treatment program which began prior to the date the Insured is covered under the Policy. 7. for crowns, inlays and onlays on teeth that can be restored by direct placement materials. 8. for the replacement of crowns, bridges, inlays, onlays or prosthetic appliance within 5 years from the date of last placement. 9. for service or supplies payable under any medical expense, auto or no-fault plan. 1. for any condition covered under any Worker s Compensation Act or similar law.. for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance. 12. for services that are applied toward the satisfaction of a Deductible, if any.. for services subject to a waiting period that were incurred during the waiting period. 14. for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services. 15. for hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, hospital confinement. 16. for drugs or the dispensing of drugs.. for oral hygiene instruction; plaque control; acid etch; prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).. for implants; myofunctional therapy; athletic mouthguards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TJ dysfunction; cleft palate; or anodontia. 19. for orthodontia, unless included within the Coverage Schedule. 2. for the replacement of a filling within 24 months of placement, unless for specific health reasons. 21. for composite, resin, or white fillings on posterior primary teeth. Benefit will be reduced to that of an amalgam or silver filling. 22. for the replacement of retainers. 23. for sealants not applied to permanent bicuspid or molar; applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth. 24. for lab fees for higher metals or porcelain crowns, bridges, inlays or onlays. 25. for general anesthesia or IV sedation. (Co-pay plans only). for services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage on Our Plan. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits. This exclusion does not apply if the device covers one or more natural teeth lost or extracted while covered under the Plan, or if the prosthetic device was in place when the policy became effective. 27. during travel or activity outside the United States. This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims. The benefits illustrated are in summary form only. They should not be construed as complete in and of themselves. They are only for comparison and in the case of discrepancy the plan documents apply. Please refer to the certificate for a complete description of benefits, limitations, and exclusions. TX INDIVIDUAL 1/8

8 Please fill out and return this enrollment form with your payment to: DENTAL SELECT - CORPORATE OICE 5373 S. GREEN STREET, 4th LOOR SALT LAKE CITY, UTAH Toll ree (8) Toll ree ax (888) PLEASE ILL OUT THE REVERSE SIDE O THIS ENROLLENT OR Enroll online at Texas - Individual Dental Plan Enrollment orm Social Security No. Last Name irst Initial Home Address City State Zip Code arital Status Requested Effective Date arried Single 1, 2 ST Date of Birth Sex Home Telephone Employer s Name & Phone Number ale emale Agent Name Agent ID Number Where did you hear about us? Do you or any family member have other dental insurance? If Yes, name other dental insurance company Yes No Person Assigned As Policy Holder Social Security No. LIST ALL DEPENDENTS TO BE COVERED irst Name Date of Birth Spouse 1. Child 2. Child 3. Child Sex irst Name D.O.B. Sex 4. Child 5. Child 6. Child 7. Child

9 Please Complete Both Sides Choose your Plan (Choose only one) Payment Options (Choose either Checking/Savings or Credit Card Payment) Discount Plan Billing Period: onthly (Withdrawn on the 16th or next 2 business days) Annual (Check or Credit Card) Silver Network Checking or Savings (Include a $15. enrollment fee with your payment) Co-Pay Plans Checking Account (Include Voided Check) Savings Account (Include Deposit Slip) Gold Network Platinum Network inancial Institution: Co-Insurance Plans Routing Number: Option 1 Option 2 Account Number: Gold Network Gold Network Credit Card Payment (Include your check for the $15. enrollment fee) Platinum Network Platinum Network VISA ASTERCARD Vision plan included with all dental Plans Account Number: Exp. Date: I wish to enroll in the plan I have selected. I authorize and agree to account deduction of the required premium. Account Holder Name: Signature: Date: Account Holder Signature: Date: This authorization will remain in effect until the financial institution has received and has had reasonable time to act on a written request from me to terminate this agreement. I understand that I can stop a withdrawal by notifying the financial institution at least three business days before the withdrawal is made. In the event of a withdrawal error, I must promptly notify the financial institution to preserve any rights I may have. Please direct billing inquiries to Dental Select, 5373 S. Green Street., 4th loor, Salt Lake City, UT I have read and understand the statements above pertaining to the billing option. Your cancellation will be effective the first day of the month following the month your written request is received. In the event there are insufficient funds when a draft is charged to my account, I agree to pay $25 NS ee. The 3rd returned check in any 12 month period will result in the immediate cancellation of my policy. Dental Select reserves the right to deny me the ability to be reinstated on any Individual Dental Select plan for two years. ACE USA is the U.S. domestic operating division of ACE Limited. Insurance products and services are provided by the U.S. insurance underwriting companies and not by ACE Limited. Gold and Platinum plans of insurance are underwritten by ACE American Insurance Company.