$33.13 per child. $ annually per child $1,000

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1 This is only a summary. If you want more detail about a child s coverage and costs under this plan, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters What is the premium amount? What is the overall deductible? Does the deductible apply to Preventive Services? What is the out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Who is included in this plan s network of providers? $33.13 per child $ annually per child No $1,000 Premiums, non-covered dental benefits, and covered dental benefits provided by out-ofnetwork dentist. No. See /WAKIDS or call for a list of participating providers. The premium amount is a monthly fee you must pay to your insurance company to receive dental insurance. You must pay all the costs related to covered services up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. The deductible does not apply to preventive exams, cleanings, or other preventive services. See the chart starting on page 2 for how much you pay for covered preventive services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for dental care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. There is no overall annual limit on what the plan will pay. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services. If you use an in-network provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network dentist may use an out-of network provider (e.g., a hospital) for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No You can see the specialist you choose without permission from this plan. You can maximize your benefits by choosing an in-network specialist. 1

2 Do I need preauthorization before receiving certain dental services? Are there services this plan doesn t cover? Yes, preauthorization is required prior to receiving services for crowns, medically necessary orthodontia and oral surgery. Yes. Your dentist must submit a request for preauthorization to your insurance plan for approval before receiving the following services (please note: a preauthorization cannot be submitted by phone): Crowns Medically Necessary Orthodontia Oral Surgery This plan does not cover adult dental services. Some of the other services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Copayments are your share of the cost of a covered service in dollars that you pay to the dentist.. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, fillings have a coinsurance of 50%. If the filling cost $100 dollars, the insurance plan will pay 50% or $50.00 and you will be responsible for 50% or $ This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the plan s allowed amount for the service. Services received from an out-ofnetwork providers will be paid based on the plan s out-of-network allowed amount. You will be responsible for the difference between the out-of-network allowed amount and the fee charged by the out-of-network provider. For example, if an out-of-network provider charges $200 for a filling and the out-of-network allowed amount is $100 and a filling has a coinsurance of 50%, the plan will pay $50 and you will pay $150. (This is called balance billing.) This plan encourages you to use in-network providers to maximize your benefits at a lower cost. routine check up Exams 0% 0% Deductible does not apply. Cleanings 0% 0% Deductible does not apply. 2

3 Fluoride 0% 0% Deductible does not apply. Topical fluoride treatment is covered up to three times per benefit period for enrollees 6 years of age and younger and twice per benefit period for all others. Topical fluoride is covered up to 3 times per 12-month period while undergoing orthodontic treatment. cavity filled other restorative care Sealants 0% 0% Deductible does not apply. X-rays 0% 0% Deductible does not apply. Nitrous oxide 50% 50% Amalgam filling 50% 50% Composite filling 50% 50% Local anesthesia 50% 50% Treatment of gums 50% 50% Crowns 50% 50% Root canals 50% 50% Replacement of teeth 50% 50% You must receive a preauthorization before service is provided. 3

4 tooth extraction advanced oral surgery medically necessary orthodontia Extraction 50% 50% Sedation 50% 50% Oral surgery 50% 50% Sedation 50% 50% Braces 50% 50% Removable appliances 50% 50% You must receive a preauthorization before service is provided. Deductible does not apply. Only Medically Necessary Orthodontia is allowed. You must receive a preauthorization before service is provided. Excluded Services & Other Covered Services: Services This Plan Does NOT Cover (This isn t a complete list. Check the policy or plan document for other excluded services.) Adult dental care Traditional braces Cosmetic services or supplies. Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Accidental Injury is covered at 100%, meaning no cost to you. Grievance and Appeals Rights 4

5 If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Claim Appeal Representative, Delta Dental of Washington, P.O. Box 75983, Seattle, WA Fax: Does this Coverage Provide Minimum Essential Coverage? This plan or policy meets the Affordable Care Act s minimum value and benefits requirements for pediatric dental care. 5