Dental Plan | Human Resources | SIU

Plan participants enrolled in the dental plan can choose any dental provider for services; however, plan participants may pay less out-of-pocket when they receive services from a network dentist.  There are two separate networks of dentists that a plan participant may utilize for dental services in addition to out-of-network providers;  The Delta Dental PPO network and the Delta Dental Premier network.

The Delta Dental PPO Network:  If you go to a PP-level dentist you can maximize your dental benefits and minimize your out-of-pocket expenses because these providers accept a lower negotiated PPO fee (less any deductible). If the PPO fess is lower than the amount listed on the Schedule of Benefits, the PPO dentist cannot bill you for the difference.

The Delta Dental Premier Network:  If you go to a Premier-level dentist your out-of-pocket expenses may also be less because Premier providers accept the allowed Premier-level fee (less any deductible).  If the allowed fee is lower than the amount listed on the Schedule of Benefits, the Premier dentist cannot bill you for the difference.

Out-of-Network:  If you go to a dentist who does not participate in either the PPO or Premier network, you will receive benefits as provided by the Schedule of Benefits. You will likely pay more than you would if you went to a Delta Dental network dentist. Out-of-network dentists will charge you for the difference between their submitted fee and the amount listed on the Schedule of Benefits.

Plan participants can access QCHP network information, explanation of benefits (EOB) statements and other valuable information online by registereing with Delta Dental of Illinois Subscriber Connection.

It is strongly recommended that plan participants obtain a pretreatment estimate for any service over $200, regardless of whether that servce is to be received from an in-network or an out-of-network provider. Failure to obtain a pretreatment estimate may result in unanticipated out-of-pocket costs. A pretreatment estimates is a review by Delta Dental or a dental provider's proposed treatment, including diagnostic, x-ray and laboratory reports, as well as the expected charges. This treatment plan is sent to Delta Dental for verification of eligible benefits. Obtaining a pretreatment estimate to verify coverage will help you make decisions regarding your dental services and help you avoid unanticipated out-of-pocket costs. Questions regarding a pretreatment estimate can be addressed by Delta Dental.

Annual Deductible for Preventative Services: N/A
Annual Deductible for All Other Covered Services: $150
Plan Year Maximum Benefits: In-Network 2,500; Out-of-Network $2,000

*Orthodontics + all other services

Annual Deductible for Preventative Services: N/A
Annual Deductible for All Other Covered Services: $175
Plan Year Maximum Benefits: In-Network 2,500; Out-of-Network $2,000

If you use a Delta Dental network dentist, you will not have to pay the dentist at the time of service (with the exception of applicable deductibles, charges for noncovered services, charges over the amount listed on the Schedule of Benefits and/or amounts over the annual maximum benefit). Network dentists will automatically file the dental claim for their patients. Participants who use an out-of-network dentist may have to pay the entire bill at the time of service and/or file their own claim form dependeing on the payment arrangements the plan participant has with their dentist.

Example of PPO, Premier and Out-of-Network Dentist Payments (this is a hypothetical example only and assumes all deductibles have been met).

Dentist submitted fee: $1,000
PPO Maximum allowed fee: $600
Schedule of Benefit amount: $781
Your Out-of-Pocket Cost: $0

Dentist submitted fee: $1,000
PPO Maximum allowed fee: $900
Schedule of Benefit amount: $781
Your Out-of-Pocket Cost: $119

Dentist submitted fee: $1,000
No Negotiated fee: N/A
Schedule of Benefit amount: $781
Your Out-of-Pocket Cost: $219

*When utilizing a PPO or Premier dentist, if the maximum allowed fee is greater than the amount listed on the Schedule of Benefits, the network dentist can bill the member the difference between the two amounts.

The child orthodontia benefit is available only to children who begin treatment prior to the age of 19.  The maximum lifetime benefit for child orthodontia is $2,000 for members utilizing an in-network provider..  This lifetime maximum isbased on the length of treatment (see "Length of Orthodonita Treatment" chart below). This lifetime maximum applies to each plan participant regardless of the number of courses of treatment. Note: The annual plan year deductible will need to be satisfied each plan year that the plan participcant is receiving orthodontia treatment unless it was previously satisfied for other dental services incurred during the plan year. FY2013 Orthodontic Schedule of Benefits and the FY2014 Orthodonic Schedule of Benefits.

Prosthodontic Limitations (Prosthodontics include full dentures, partial dentures, implants and crowns)
Prosthodontics to replace missing teeth are covered only for teeth that are lost while the pan participants is covered by this QCDP.  Multiple procedures are subject to limitations.  Please refer to the Dental Schedule of Benefits PRIOR to the start of any procedure to clarify coverage limitations.
Claim Forms for Delta Dental

Any service received through June 30, 2011 will still be administered by CompBenefits. For questions on services provided by CompBenefits, they may be reached at 800-999-1669. Reimbursements will be subject to the claims hold.

CompBenefits (ends on June 30,2011)
Group Number 950
PO Box 4677
Chicago  IL  60680-4677
800-999-1669
www.compbenefits.com