Delta Dental Plan

8/10/2019 Delta Dental Plan

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XIP-DC-ENT-15 v15

Delta Dental Individual & Family

Delta Dental PPOSM

Preferred Plan for Famil ies

Combined Policy and Disclosure Form

Provided by:

Delta Dental Insurance Company

Limited Benefits, Please Read Carefully

deltadentalins.com

www.dchbx.com855-532-5465
http://www.dchbx.com/http://www.dchbx.com/


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Policy

You must make an election on the Exchange for any eligible person you wish to cover underthis Policy. If an election is not made on the Exchange for an individual or dependent, suchperson will not be eligible under this Policy.

Your dental plan is underwritten and administered by Delta Dental Insurance Company (DeltaDental). Delta Dental will pay Benefits for covered dental services as set forth in this Policy.This Policy is issued in exchange for paymentof the first installment of Premium and on thebasis of the statements made on your application through the Exchange. It takes effect on theEffective Date shown in the Policy Variables attached to this Policy. This Policy will remain inforce unless otherwise terminated in accordance with its terms,until the first renewal dateand for such further periods for which it is renewed. All periods willbegin and end at 12:01

A.M., Standard Time, where you live.

LIMITED BENEFITS, READ YOUR POLICY AND ATTACHMENTS CAREFULLY

Ten (10)-DAY RIGHT TO EXAMINE AND RETURN THIS POLICY

Please read this Policy. If this Policy was solicited by deceptive advertising or negotiated bydeceptive, misleading, or untrue statements or if you are not satisfied, you may return thisPolicy within ten (10) days after you received it. Mail or deliver it to Delta Dental. Any Premiumpaid will be refunded. If you received services under this Policy during the 10-day period, youmust pay for those services. This Policy will then be void from its start.

This Policy is signed for Delta Dental Insurance Company as of its Effective Date by:

Anthony S. Barth, President


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Table of Contents

INTRODUCTION ..................................................................................................................................................... 1

DEFINITIONS .......................................................................................................................................................... 2

ELIGIBILITY AND ENROLLMENT ......................................................................................................................... 5

OVERVIEW OF DENTAL BENEFITS .................................................................................................................... 7

SELECTING YOUR PROVIDER............................................................................................................................. 9

GRIEVANCES AND APPEALS ............................................................................................................................ 11

PREMIUM PAYMENT RESPONSIBILITIES ........................................................................................................ 14

GENERAL PROVISIONS ..................................................................................................................................... 16

ATTACHMENTS:

POLICY VARIABLES

ATTACHMENT A DEDUCTIBLES, MAXIMUMS, POLICY BENEFIT LEVELS AND ENROLLEE

COINSURANCES

ATTACHMENT B SERVICES, LIMITATIONS AND EXCLUSIONS

DC GUARANTY ASSOCIATION NOTICE


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INTRODUCTION

We are pleased to welcome you to this individual Delta Dental PPOSM

dental plan. Our goal is toprovide you with the highest quality dental care and to help you maintain good dental health. Weencourage you not to wait until you have a problem to see the dentist, but to see him or her on aregular basis.

Eligibility under this Policy is determined by the Exchange. This Policy provides dental benefitsfor adults and children as defined in the following sections:

Eligibility Requirement for Pediatric Benefits(Essential Health Benefits)

Eligibility Requirement for Adult Benefits

NOTICE: YOUR SHARE OF THE PAYMENT FOR HEALTH CARE SERVICES MAY BEBASED ON THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER.UNDER CERTAIN CIRCUMSTANCES THIS AGREEMENT MAY ALLOW YOUR PROVIDERTO BILL YOU FOR AMOUNTS UP TO THE PROVIDERS REGULAR BILLED CHARGES.

Using This Policy

This Policy discloses the terms and conditions of your coverage and is designed to help youmake the most of your dental plan. It will help you understand how the dental plan works andhow to obtain dental care. Please read this Policy completely and carefully. Keep in mind thatyou and your mean the Enrollees who are covered under this Policy. We, us and ouralways refer to Delta Dental.

Contact Us

If you have any questions about your coverage that are not answered here, please visit ourwebsite at deltadentalins.com or call our Customer Service Center. A Customer Servicerepresentative can answer questions you may have about obtaining dental care, help you locatea Delta Dental Provider, explain Benefits, check the status of a claim and assist you in filing aclaim.

You can access our automated information line at 800-471-0275 to obtain information aboutEnrollee Benefits, claim status or to speak to a Customer Service representative for assistance.If you prefer to write to us with your question(s), please mail your inquiry to the followingaddress:

Delta Dental Insurance Company

One Delta Drive

Mechanicsburg, PA 17055


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Identification Number

Please provide the Enrollees identification (ID) number to your Provider whenever you receivedental services. The Enrollee ID number should be included on all claims submitted forpayment. ID cards are not required, but if you wish to have one you may obtain one by visiting

our website at deltadentalins.com.

DEFINITIONS

The following are definitions of words that have special or technical meanings under this Policy.

Accepted Fee:the amount the attending Provider agrees to accept as payment in full forservices rendered.

Adult Benefits: dental services under this Policy for people age 19 years and older.

Benefits:the amounts that Delta Dental will pay for covered dental services under this Policy.

Calendar Year:the 12 months of the year from January 1 through December 31.

Claim Form:the standard form used to file a claim, request a Pre-Treatment Estimate orrequest prior authorization.

Deductible: a dollar amount that an Enrollee must satisfy for certain covered services beforeDelta Dental begins paying Benefits.

Delta Dental PPO Contracted Fee (PPO Providers Contracted Fee ):the fee for eachSingle Procedure that a PPO Provider has contractually agreed to accept as payment in full fortreating Enrollees.

Delta Dental PPO Provider(PPO Provider ):a Provider who contracts with Delta Dental or

any other member company of the Delta Dental Plans Association and agrees to accept theDelta Dental PPO Contracted Fee as payment in full for services provided under a PPO plan. APPO Provider also agrees to comply with Delta Dentals administrative guidelines.

Delta Dental PremierContracted Fee (Premier Providers Contracted Fee): the fee for

each Single Procedure that a Premier Provider has contractually agreed to accept as paymentin full for treating Enrollees.

Delta Dental Premier Provider ( Premier Provider ):a Provider who contracts with DeltaDental or any other member company of the Delta Dental Plans Association and agrees toaccept the Delta Dental Premier Contracted Fee as payment in full for services provided under aplan. A Premier Provider also agrees to comply with Delta Dentals administrative guidelines.

Effective Date:the original date the plan starts.Eligible Dependent:a person who is a dependent of an Eligible Primary and considered to bea Qualified Individual by the Exchange. Eligible Dependents are eligible for either PediatricBenefits or Adult Benefits as described in this Policy.

Eligible Primary:a person who is considered to be a Qualified Individual by the Exchange.Eligible Primaries are eligible for either Pediatric Benefits or Adult Benefits as described in thisPolicy.


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Eligible Pediatric Individual:a person who is considered to be a Qualified Individual by theExchange. Eligible Pediatric Individuals are eligible for Pediatric Benefits as described in thisPolicy.

Enrollee: an Eligible Primary (Primary Enrollee), Eligible Dependent (Dependent Enrollee) orEligible Pediatric Individual (Pediatric Enrollee) enrolled under this Policy to receive Benefits;

persons eligible and enrolled under this Policy for Adult Benefits may also be referred to asAdult Enrollees.

Enrol lee Pays:an Enrollees financial obligation for services calculated as the differencebetween the amount shown as the Accepted Fee and the portion shown as Delta DentalPays on the claims statement when a claim is processed.

Essential Health Benefits ( Pediatric Benefits ): for the purposes of this Policy, EssentialHealth Benefits are certain pediatric oral services that are required to be included in this Policyunder the Affordable Care Act. The services considered to be Essential Health Benefits aredetermined by state and federal agencies and are available for Eligible Pediatric Individuals.

Exchange: the District of Columbia Exchange also referred to as The DC Health BenefitExchange Authority.

Maximum: the maximum dollar amount we will pay toward the cost of dental care.

Maximum Contract Allowance:the reimbursement under the Enrollees benefit plan againstwhich Delta Dental calculates its payment and the financial obligation for the Enrollee. Subjectto adjustment for extreme difficulty or unusual circumstances, the Maximum Contract Allowancefor services provided:

by a PPO Provider is the lesser of the Submitted Fee or the PPO Providers ContractedFee; or

by a Premier Provider is the lesser of the Submitted Fee or the PPO ProvidersContracted Fee for a PPO Provider in the same geographic area; or

by a Non-Delta Dental Provider is the lesser of the Submitted Fee or the PPO ProvidersContracted Fee for a PPO Provider in the same geographic area.

Non-Delta Dental Provider:a Provider who is not a PPO Provider or a Premier Provider andwho is not contractually bound to abide by Delta Dentals administrative guidelines.

Open Enrollment Period: the period of the year that the Exchange has established when thePrimary Enrollee may change coverage selections for the next Policy Year.

Out-of-Pocket Maximum: the maximum amount that a Pediatric Enrollee must satisfy forcovered dental services during the Calendar Year provided a PPO Provider is used.

Coinsurance and other cost-sharing, including balance billed amounts, will continue to apply forcovered services from a Premier or Non-Delta Dental Provider even after the Out-of-PocketMaximum has been met.

Policy:this agreement between Delta Dental and the Primary Enrollee including any applicationsupplied by the Exchange and any Attachments. This Policy constitutes the entire agreementbetween the parties.


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Policy Benefit Level:the percentage of the Maximum Contract Allowance that Delta Dental willpay.

Policyholder: the Primary Enrollee who enrolls for coverage.

Policy Year: the 12 months starting on January 1st and each subsequent 12 month period

thereafter. Policy Year can be less than 12 months if an Enrollee has an Effective Date mid-yeardue to a Qualifying Status Change or other exceptional circumstance as determined by theExchange.

Premium: the amount payable as provided in the Policy Variables attached to this Policy.

Pre-Treatment Estimate:an estimation of the allowable Benefits under this Policy for theservices proposed, assuming the person is an eligible Enrollee.

Procedure Code:the Current Dental Terminology (CDT)number assigned to a SingleProcedure by the American Dental Association.

Provider:a person licensed to practice dentistry when and where services are performed. AProvider shall also include a dental partnership, dental professional corporation or dental clinic.

Qualified Individual:an individual determined by the Exchange to be eligible to enroll throughthe Exchange.

Qualifying Status Change:

marital status (marriage, divorce, legal separation, annulment or death);

number of dependents (a childs birth, adoption of a child, placement of child for adoption,addition of a step or foster child or death of a child);

dependent child ceases to satisfy eligibility requirements;

residence (Enrollee moves);

court order requiring dependent coverage;

loss of minimal essential coverage; or

any other current or future election changes permitted by the Exchange.

Single Procedure:a dental procedure that is assigned a separate Procedure Code.

Spouse:a person related to or a partner of the Primary Enrollee:

as defined and as may be required to be treated as a Spouse by the laws of the statewhere this Policy is issued and delivered;

as defined as a person of the same or opposite sex who is legally married to the PrimaryEnrollee under the laws of the state or jurisdiction in which the marriage took place; or

as defined and as may be required to be treated as a Spouse by the laws of the statewhere the Primary Enrollee resides.

Submitted Fee: the amount that the Provider bills and enters on a claim for a specificprocedure.


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Waiting Period: the amount of time an Enrollee must be enrolled under this Policy for specificservices to be covered.

ELIGIBILITYANDENROLLMENT

The Exchange is responsible for establishing eligibility and reporting enrollment to us. Weprocess enrollment as reported by the Exchange.

This Policy includes Pediatric Benefits and Adult Benefits. Enrollees are eligible for eitherPediatric or Adult Benefits according to the requirements listed below:

Eligibil ity Requirement for Pediatric Benefits

Pediatric Enrollees are Qualified Individuals as determined by the Exchange who are eligibleand have enrolled for Pediatric Benefits under this Policy. A Qualified Individual must satisfy theExchanges requirements regarding:

citizenship, status as a national or otherwise lawfully present in the United States;

incarceration; and

residency.

Pediatric Enrollees eligible for Pediatric Benefits are:

a Primary Enrollee or an emancipated minor to age 19; and/or

a Primary Enrollees Spouse under age 19 and dependent children from birth to age 19.Dependent children include natural children, stepchildren, foster children, adoptedchildren, children placed for adoption and children of Spouse.

Eligibil ity Requirement for Adul t Benefits

Primary Enrollees and Dependent Enrollees are Qualified Individuals as determined by theExchange who are eligible and have enrolled for Adult Benefits under this Policy. A QualifiedIndividual must satisfy the Exchanges requirements regarding:

citizenship, status as a national or otherwise lawfully present in the United States;

incarceration; and

residency.

Adult Enrollees eligible for Adult Benefits are:

a Primary Enrollee age 19 years of age or older; and/or

a Primary Enrollees Spouse age 19 and older and dependent children from age 19 toage 26. Dependent children include natural children, stepchildren, foster children,adopted children, children placed for adoption and children of Spouse.


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fraud or material misrepresentation made by or with the knowledge of the PrimaryEnrollee or the Enrollee applying for this coverage or filing a claim for Benefits;

the Primary Enrollee changing to a new policy through the Exchange; or

Delta Dental ceasing to renew all Policies issued on this form to residents of the state

where you live.If your coverage is terminated, we will send a written notice to you informing you of thereasons(s) why coverage is terminated and the date that your coverage will end. We will not payfor services received after the date coverage ends. However, we will pay for the completion ofSingle Procedures started while an Enrollee was eligible if they are completed within 31 days ofthe date coverage ended.

Reinstatement

If this Policy is terminated, you may re-enroll in the plan at the next Open Enrollment Period.Any Deductible, Maximum, Out-of-Pocket Maximum and/or Waiting Period applicable to yourBenefits will start over. However, this Policy will be reinstated prior to Open Enrollment with nobreak in coverage as long as you pay any past due Premium within 90 days of the past duedate(see Grace Period on Late Payments). Once we receive your past due Premium we willreinstate this Policy within 45 days. If you reinstate by paying past due Premium within the 90days, a new application is not required. The reinstated Policy will have the same rights asbefore your Policy lapsed, unless a change is made to this Policy in connection with thereinstatement. These changes, if any, will be sent to you for you to attach to this Policy.

OVERVIEW OF DENTAL BENEFITS

This section provides information that will give you a better understanding of how the dental planworks and how to make it work best for you.

Benefits , Limitations and Exclusions

We will pay Benefits for the types of dental services as described in the Attachments that are apart of this Policy.

We will pay Benefits only for covered services. This Policy covers several categories of Benefitswhen a Provider furnishes the services and when they are necessary and within the standardsof generally accepted dental practice. Claims shall be processed in accordance with ourstandard processing policies. We may use dentists (dental consultants) to review treatmentplans, diagnostic materials and/or prescribed treatments to determine generally accepted dentalpractices and to determine if treatment has a favorable prognosis. If you receive dental servicesfrom a Provider outside the District of Columbia, the Provider will be paid according to DeltaDentals network payment provisions for said state and according to terms of the ProvidersContract.


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If a primary dental procedure includes component procedures that are performed at the sametime as the primary procedure, the component procedures are considered to be part of theprimary procedure for purposes of determining the Benefit payable under this Policy. Even if theProvider bills separately for the primary procedure and each of its component parts, the totalBenefit payable for all related charges will be limited to the maximum Benefit payable for the

primary procedure.

Enrollee Coinsurance

We will pay a percentage of the Maximum Contract Allowance for covered services, subject tocertain limitations, and you are responsible for paying the balance. What you pay is called theenrollee coinsurance (Enrollee Coinsurance) and is part of your out-of-pocket cost. You mayhave to satisfy a Deductible before we will pay Benefits. You pay the Enrollee Coinsurance evenafter a Deductible has been met.

The amount of your Enrollee Coinsurance will depend on the type of service and the Providerfurnishing the service (see section titled Selecting Your Provider). Providers are required to

collect Enrollee Coinsurance for covered services. If the Provider discounts, waives or rebatesany portion of the Enrollee Coinsurance to you, we will be obligated to provide as Benefits onlythe applicable percentages of the Providers fees or allowances reduced by the amount of thefees or allowances that is discounted, waived or rebated.

It is to your advantage to select PPO Providers because they have agreed to accept theMaximum Contract Allowance as payment in full for covered services, which typically results inlower out-of-pocket costs for you. Please refer to the section titled Selecting Your Provider formore information.

Pre-Treatment Estimates

Pre-Treatment Estimate requests are not required; however, your Provider may file a ClaimForm before beginning treatment, showing the services to be provided to you. We will estimatethe amount of Benefits payable under this Policy for the listed services. By asking your Providerfor a Pre-Treatment Estimate from us before the Enrollee receives any prescribed treatment, youwill have an estimate up front of what we will pay and the difference you will need to pay. TheBenefits will be processed according to the terms of this Policy when the treatment is actuallyperformed. Pre-Treatment Estimates are valid for 365 days or until an earlier occurrence of anyone of the following events:

the date this Policy terminates;

the date the Enrollees coverage ends; or the date the Providers agreement with Delta Dental ends.

A Pre-Treatment Estimate does not guarantee payment. It is an estimate of the amount we willpay if you are covered and meet all the requirements of the plan at the time the treatment youhave planned is completed and may not take into account any Deductibles, so please rememberto figure in your Deductible if necessary.


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SELECTING YOUR PROVIDER

Free Choice of Provider

You may see any Provider for your covered treatment whether the Provider is a PPO Provider,

Premier Provider or a Non-Delta Dental Provider. This plan offered through the Exchange isa PPO plan and the greatest benefits including out-of-pocket savings occur when youchoose a PPO Provider.To take full advantage of your Benefits, we highly recommend youverify a dentists participation status within a Delta Dental network with your dental office beforeeach appointment. Review this section for an explanation of Delta Dental payment proceduresto understand the method of payments applicable to your Provider selection and how that mayimpact your out-of-pocket costs.

Locating a PPO Provider

You may access information through our website at deltadentalins.com. You may also call ourCustomer Service Center and one of our representatives will assist you. We can provide youwith information regarding a Providers network participation, specialty and office location.

Choosing a PPO Provider

The PPO plan potentially allows the greatest reduction in Enrollees out-of-pocket expensessince this select group of Providers will provide dental Benefits at a charge that has beencontractually agreed upon. Payment for covered services performed by a PPO Provider isbased on the Maximum Contract Allowance.

Costs incurred by the Pediatric Enrollee for covered services with a PPO Provider apply towards

the Out-of-Pocket Maximum for Pediatric Benefits.

Choosing a Premier Provider

A Premier Provider is a Delta Dental Provider; however, the Premier Provider has not agreed tothe features of the PPO plan. The amount charged may be above that accepted by PPOProviders, and Enrollees will be responsible for balance billed amounts. Payment for coveredservices performed by a Premier Provider is based on the Maximum Contract Allowance, andthe Enrollee may be balance billed up to the Premier Providers Contracted Fee.

Costs incurred by the Pediatric Enrollee with a Premier Provider do not count towards the Out-of-Pocket Maximum for Pediatric Benefits. Coinsurance and other cost-sharing, includingbalance billed amounts, continue to apply when a Premier Provider is used even if the Out-of-Pocket Maximum for Pediatric Enrollees has been met.


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Choosing a Non-Delta Dental Provider

If a Provider is a Non-Delta Dental Provider, the amount charged to Enrollees may be abovethat accepted by PPO Providers or Premier Providers, and Enrollees will be responsible forbalance billed amounts. Payment for covered services performed by a Non-Delta Dental

Provider is based on the Maximum Contract Allowance, and the Enrollee may be balance billedup to the Providers Submitted Fee.

Costs incurred by the Pediatric Enrollee with a Non-Delta Dental Provider do not count towardsthe Out-of-Pocket Maximum for Pediatric Benefits. Enrollee Coinsurance and other cost-sharing,including balance billed amounts, continue to apply when a Non-Delta Dental Provider is usedeven if the Out-of-Pocket Maximum for Pediatric Enrollees has been met.

Addi tional Obl igations of PPO Providers

The PPO Provider or Premier Provider must accept assignment of Benefits, meaningthese Providers will be paid directly by Delta Dental after satisfaction of the Deductibleand Enrollee Coinsurance. The Enrollee does not have to pay all the dental chargeswhile at the dental office and then submit the claim for reimbursement.

The PPO Provider or Premier Provider will complete the dental Claim Form and submit itto Delta Dental for reimbursement.

The PPO Provider will accept contracted fees as payment in full for covered services andwill not balance bill if there is a difference between Submitted Fees and Delta DentalPPO Contracted Fees.

How to Submit a Claim

Claims for Benefits must be filed on a standard Claim Form that is available in most dentaloffices. PPO and Premier Providers will fill out and submit your claims paperwork for you. SomeNon-Delta Dental Providers may also provide this service upon your request. If you receiveservices from a Non-Delta Dental Provider who does not provide this service, you can submityour own claim directly to us. Please refer to the section titled Claim Form for moreinformation.

Your dental office should be able to assist you in filling out the Claim Form. Fill out the ClaimForm completely and send it to:

Delta Dental of the District of Columbia

P.O. Box 2105Mechanicsburg, PA 17055-2105


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Payment Guidelines

We do not pay PPO or Premier Providers any incentive as an inducement to deny, reduce, limitor delay any appropriate service.

If you or your Provider files a claim for services more than 12 months after the date you received

the services, payment may be denied. If the services were received from a Non-Delta DentalProvider, you are still responsible for the full cost. If the payment is denied because your PPO orPremier Provider failed to submit the claim on time, you may not be responsible for thatpayment.However, if you did not tell your PPO or Premier Provider that you were coveredunder a Delta Dental Policy at the time you received the service, you may be responsible for thecost of that service.

If you have any questions about any dental charges, processing policies and/or how your claimis paid, please contact us.

Provider Relationships

The Primary Enrollee and Delta Dental agree to permit and encourage the professionalrelationship between Provider and Enrollee to be maintained without interference. Any PPO,Premier or Non-Delta Dental Provider, including any Provider or employee associated with oremployed by them, who provides dental services to an Enrollee does so as an independentcontractor and shall be solely responsible for dental advice and for performance of dentalservices, or lack thereof, to the Enrollee.

GRIEVANCES AND APPEALS

Informal Internal Review

If you have questions about any services received, we recommend that you first discuss thematter with your Provider. However, if you continue to have concerns, please call our CustomerService Center. You can also email questions by accessing the Contact Us section of ourwebsite at deltadentalins.com.

You may also designate an outside independent representative to assist you in followinggrievance procedures.

Grievances regarding eligibility, the denial of dental services or claims, the policies, procedures,operations of Delta Dental or the quality of dental services performed by the Provider may bedirected in writing to us or by calling us toll-free at 800-471-0275.

When you write, please include the name of the Enrollee, the ID number and your telephonenumber on all correspondence. You should also include a copy of the Claim Form, claimstatement or other relevant information. Your claim statement will have an explanation of theclaim review and any grievance process and time limits applicable to such process.

We will notify you and your Provider if Benefits are denied for services submitted on a ClaimForm, in whole or in part, based upon lack of medical necessity. This notification will include adescription of the procedures for filing grievances. Any such denial will be based upon a


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determination by a Provider who holds a non-restricted license in the same or an appropriatespecialty that typically manages the dental condition, procedure or treatment under review. Youand your Provider have at least 180 days after receiving a notice of denial to request a review inwriting to Delta Dental giving reasons why you believe the denial was wrong. You may also askDelta Dental to examine any additional information you include that may support your grievance.

Send your grievance to us at the address shown below:


P.O. Box 2105

Mechanicsburg, PA 17055-2105

We will send you a written acknowledgment within five (5) days upon receipt of your grievance.We will make a full and fair review within 14 business days after we receive the grievance. Wemay ask for more documents if needed. We will send you a decision within 14 business days. Ifthe grievance is an appeal from a determination regarding urgent or emergency care, we willconclude the appeal within 24 hours of receiving notification of appeal from you or your

representative. The review will take into account all comments, documents, records or otherinformation, regardless of whether such information was submitted or considered initially. If thereview is of a denial based in whole or in part on lack of dental necessity, experimentaltreatment or clinical judgment in applying the terms of this Policy, we shall consult with a dentistwho has appropriate training and experience. The review will be conducted for us by a personwho is neither the individual who made the claim denial that is subject to the review, nor thesubordinate of such individual.

Formal Internal Review

If you believe you need further review of your claim and/or your grievance, you may file an

appeal by requesting from us a second level of review.

Our formal review appeals process provides you with the opportunity to pursue your appealbefore a reviewer or panel of Providers we select. We will acknowledge receipt of your requestto pursue a formal review appeal in writing within 10 business days of receipt. After we receiveall the necessary documentation from you and your Provider, our formal internal appeal processwill be conducted as soon as possible.

If the formal internal appeal is from a decision regarding urgent or emergency care, we willconclude the appeal within 24 hours from the time you or your Provider provide us notification ofthe appeal. All other appeals under this process will be concluded within 30 business days,unless you request an extension of time.

If we deny your formal internal appeal, we will provide you or your representative with a writtenexplanation of the denial and written notification of your right to proceed to an external appeal.This denial will be accompanied by all necessary forms for you to initiate the external appeal.


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Formal External Review

Should you remain dissatisfied with the resolution of your grievance, you have the right tocontact the Director of Insurance in pursuit of a formal external appeal. Within 30 business daysfrom receipt of the written decision of the formal internal appeal panel, you or yourrepresentative may initiate an external appeal by filing a written requires with the Director ofInsurance. Your request must be accompanied by a signed form allowing us to release medicalrecords that are pertinent to the appeal.

Upon receipt of the request for an external appeal, together with the executed release form, theDirector will determine whether:

You were or are a member of the benefit plan;

The service which is the subject of the appeal reasonably appears to be a servicecovered under the benefit plan;

You or your representative have fully complied with the state laws regarding informal andformal internal appeals; and

You or your representative have provided all information required by the independentreview organization and the Director to make the preliminary determination, including theappeal form, and a copy of any information provided by us regarding our decision todeny, reduce or terminate a covered service, and the release form.

Upon completion of the preliminary review, the Director will notify you or your representative andus as to whether the appeal has been accepted for processing. If the appeal is accepted by theDirector, the Director will assign the appeal to an independent review organization (IRO) for fullreview. If the appeal is not accepted by the Director, the Director will provide a statement of thereasons for the non-acceptance to you or your representative and to us.

Upon acceptance of the appeal for processing, the IRO will conduct a full review to determinewhether, as a result of our decision, you were deprived of any service covered by this Policy.

We will provide all documentation to the IRO within 5 days of receipt of the notice of approval ofthe appeal by the Director, or within 24 hours of receipt of the notice of approval of thegrievance, for an expedited review.

The full review of an appeal will be initially conducted by at least 2 licensed Providers. Inreaching its determination, the IRO will take into consideration all pertinent medical records,consulting Provider reports, and other documents submitted by you and us, and any applicablegenerally accepted dental practice guidelines developed by the federal government, nation orprofessional dental societies, boards and associations, any applicable clinical protocols orpractice guidelines developed by us, and may consult with other professionals as appropriate

and necessary.

You or your representative may request to appear in person before the independent revieworganization. The organization will conduct a hearing as soon as possible after receiving arequest from you or your representative to appear before the IRO. The IRO will notify you oryour representative and us, either orally or in writing, of the hearing date and location. At thehearing, you will be permitted to present your case, submit any supporting material, ask


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P.O. Box 660138

Dallas, TX 75266-0138

Rate Guarantee

Your Premium rate is guaranteed for each Policy Year based upon the new Enrollee rates inforce at the time of your enrollment. The rate guarantee can be less than 12 months if anEnrollee has an Effective Date mid-year due to a Qualifying Status Change or due to otherextraordinary circumstance as determined by the Exchange.

Changing Payment Options

Payment options may be changed at any time. The effective date of any change is the date ofthe next scheduled payment based on your new billing period. You can change your payment

option by visiting our website at deltadentalins.com or by contacting our Customer ServiceCenter toll-free at 800-471-0275.

Grace Period on Late Payments

For Enrollees receiving an Advanced Premium Tax Credit (APTC):

If your Premium payment is not received by the first of the month, a grace period of three(3) months will be granted. During the grace period, this Policy shall continue in force.However, your coverage for the second and third months of the grace period will besuspended and claims incurred during the second and third months of the grace periodwill not be paid unless all Premiums due are paid prior to the expiration of the graceperiod. If Premiums are received during the grace period, then the Enrollees will bereinstated as of the last day of paid coverage. If Premiums are not received prior to theend of the grace period, coverage will be terminated as of the end of the last day of thefirst month of the grace period.

For Enrollees not receiving an Advanced Premium Tax Credit (APTC):

A grace period of 31 days will be granted for the payment of each Premium falling dueafter the first Premium. During this time this Policy shall continue in force. If yourcoverage terminates for non-payment, you will be responsible for the cost of servicesrendered during the grace period. Coverage will terminate at the end of the grace periodunless we receive your Premium before the end of this 31 days.


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GENERAL PROVISIONS

Entire Contract; Changes

This Policy, including any Attachments, constitutes the entire contract of insurance. No change

to this Policy shall be valid until approved by our executive officer and unless such approval isendorsed hereon or attached hereto. No agent has authority to change this Policy or to waiveany of its provisions.

Severability

If any part of this Policy or an amendment of it is found by a court or other authority to be illegal,void or not enforceable, all other portions of this Policy will remain in full force and effect.

Incontestability

After three (3) years from the date of issue of this Policy, no misstatements, except fraudulentmisstatements, made by you in the application for this Policy will be used to void this Policy or todeny a claim for loss incurred or disability commencing after the expiration of such 3-yearperiod.

No claim for loss incurred or disability commencing after three (3) years from the date of issue ofthis Policy shall be reduced or denied on the grounds that a disease or physical condition notexcluded from coverage by name or specific description effective on the date of loss existedprior to the Effective Date of this Policy.

Clinical Examination

Before approving a claim, we will be entitled to receive, to such extent as may be lawful,information and records relating to the treatment provided to you as may be required toadminister the claim. Examination may be required by a dental consultant retained by us in ornear your community or residence. We will in every case hold such information and recordsconfidential.

Written Notice of Claim/Proof of Loss

We must be given written proof of loss within 12 months after the date of the loss. Failure tofurnish such proof within the time required will not invalidate nor reduce any claim if it was not

reasonably possible to give written proof in the time required provided that the proof is filed assoon as reasonably possible. A notice of claim submitted by you, on your behalf, or on behalf ofyour beneficiary to us or to our authorized agent, with information sufficient to identify you will beconsidered notice of claim.


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XIP-DC-ENT-15 17

All written proof of loss must be given to us within 12 months of the termination of this Policy.

Send your Notice of Claim/Proof of Loss to us at the address shown below:


P.O. Box 2105

Mechanicsburg, PA 17055-2105

Claim Form

We will within 15 days after receiving a notice of a claim provide you or your Provider with aClaim Form to make claim for Benefits. To make a claim, the form should be completed andsigned by the Provider who performed the services and by the patient (or the parent or guardianif the patient is a minor) and submitted to us at the address above.

If we do not send you or your Provider a Claim Form within 15 days after you or your Providergave us notice regarding a claim, the requirements for proof of loss outlined in the section

Written Notice of Claim/Proof of Loss above will be deemed to have been complied with aslong as you give us written proof that explains the type and the extent of the loss that you aremaking a claim for within the time established for filing proofs of loss. You may also download aClaim Form from our website at deltadentalins.com.

Time of Payment

Claims payable under this Policy for any loss other than loss for which this Policy provides anyperiodic payment will be processed immediately after written proof of loss is received in the formrequired by the terms of this Policy. We will notify you and your Provider of any additionalinformation needed to process the claim.

Physical Examination and Autopsy

Delta Dental at its own expense shall have the right and opportunity to examine the person ofthe insured when and as often as it may reasonably require during the pendency of a claimhereunder and to make an autopsy in case of death where it is not forbidden by law.

To Whom Benefits Are Paid

It is not required that the service be provided by a specific dentist. Payment for services

provided by a PPO or Premier Provider will be made directly to the Provider. Any otherpayments provided by this Policy will be made to you unless you request in writing when filing aproof of claim that the payment be made directly to the Provider providing the services. AllBenefits not paid to the Provider will be payable to you or to your estate, or to an alternaterecipient as directed by court order, except that if the person is a minor or otherwise notcompetent to give a valid release, Benefits may be payable to his or her parent, guardian orother person actually supporting him or her.


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XIP-DC-ENT-15 18

Misstatements on Appl ication; Effect

In the absence of fraud or intentional misrepresentation of material fact in applying for orprocuring coverage under this Policy, all statements made by you will be deemedrepresentations and not warranties. No such statement will be used in defense to a claim under

this Policy unless it is contained in a written application. If any misstatement would materiallyaffect the rates, we reserve the right to adjust the Premium to reflect your actual circumstancesat time of application or to terminate your Policy.

Legal Actions

No action at law or in equity will be brought to recover on this Policy prior to expiration of 60days after proof of loss has been filed in accordance with requirements of this Policy. No actioncan be brought at all unless brought within three (3) years from expiration of the time withinwhich proof of loss is required by this Policy.

Conformity with Applicable Laws

All legal questions about this Policy will be governed by theDistrict of Columbia where thisPolicy was entered into and is to be performed. Any part of this Policy that conflicts with the lawsof the District of Columbia or federal law is hereby amended to conform to the minimumrequirements of such laws.

Holding Company

Delta Dental is a member of the insurance holding company system of Delta Dental of California(the Enterprise). There are service agreements between and among the controlled member

companies of the Enterprise. Delta Dental is a party to some of these service agreements. It isexpected that the services, which include certain ministerial tasks, will continue to be performedby these controlled member companies, which operate under strict confidentiality and/orbusiness associate agreements. All such service agreements have been approved by therespective regulatory agencies.

Third Party Administrator ( TPA )

Delta Dental may use the services of a TPA, duly registered under applicable state law, toprovide services under this Policy. Any TPA providing such services or receiving suchinformation shall enter into a separate business associate agreement with Delta Dentalproviding that the TPA shall meet HIPAA and HITECH requirements for the preservation ofprotected health information of Enrollees.


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PVHCR-DC-ENT-15

POLICY VARIABLES

Policyholder:

Effective Date:

Policy Year:

Policy ID Number:

Premium Remittance:

Each Premium is to be paid to:


P.O. Box 660138

Dallas, TX 75266-0138

Monthly Premium:

Taylor Dankmyer

02/01/2015

113484820401


23/42XIAtAhi-DC-ENT-15 1

Attachment ADeductibles, Maximums, Policy Benefit Levels and Enrollee Coinsurances

Deductibles & MaximumsAdul t Benef its

(age 19 and older)Pediatric Benefits

(under age 19)

Annual Deduct ib le The annual Deductible is waived for Diagnostic and Preventive Services.

Enrollee $50 each Calendar Year $85 each Calendar YearFamily (three or more Enrollees) $150 each Calendar Year No family Deductible

Annual Maximum

Enrollee $1,000 each Calendar Year No annual Maximum

Out-of-Pocket Maximum*

Pediatric Enrollee $350 each Calendar Year for only one covered Pediatric Enrollee

Multiple Pediatric Enrollees $700 each Calendar Year for two or more covered Pediatric Enrollees

Out-of-Pocket Maximum applies only to Essential Health Benefits for Pediatric Enrollees. Out-of-PocketMaximum means the maximum amount of money that a Pediatric Enrollee must pay for covered dental

services under this Policy during a Calendar Year provided Delta Dental PPO Providers are used. EnrolleeCoinsurance and other cost sharing, including balance billed amounts, will continue to apply for coveredservices from Delta Dental Premier or Non-Delta Dental Providers even after the Out-of-Pocket Maximum ismet.

If only one Pediatric Enrollee is covered under this Policy, the financial obligation for covered services receivedfrom Delta Dental PPO Providers is not more than the Pediatric Enrollee Out-of-Pocket Maximum. If two ormore Pediatric Enrollees are covered under this Policy, the financial obligation for covered services receivedfrom Delta Dental PPO Providers is not more than the multiple Pediatric Enrollees Out-of-Pocket Maximum.Once the amount paid by the Pediatric Enrollee(s) equals the Out-of-Pocket Maximum shown above, no furtherpayment will be required by the Pediatric Enrollee(s) for the remainder of the Calendar Year for coveredservices received from Delta Dental PPO Providers.

Policy Benefit Levels & Enrollee CoinsurancesAdul t Benef its

(age 19 and older)Pediatric Benefits

(under age 19)

Dental Service Category Delta Dental PPO1 Delta Dental PPO

1

Delta Dental2 Enrollee

2 Delta Dental

2 Enrollee

2

Diagnostic and PreventiveServices

100% 0% 100% 0%

Basic Services 80% 20% 80% 20%

Major Services 50% 50% 50% 50%

Medically Necessary OrthodonticServices

(requires prior authorization)

Not a coveredbenefit

Not a coveredbenefit

50% 50%

Waiting Periods

Major Services are limited to AdultEnrollees who have been enrolled

under this Policy for 12 consecutivemonths.

3

Medically necessary OrthodonticServices are limited to Pediatric

Enrollees who have been enrolledunder this Policy for 12 consecutive

months.4


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1Reimbursement is based on Delta Dental PPOContracted Fees for Delta Dental PPO, Delta Dental PremierandNon-Delta Dental Providers.

2Delta Dental will pay or otherwise discharge the Policy Benefit Level according to the Maximum Contract Allowancefor covered services. Note: Delta Dental will pay the same Policy Benefit Level for covered services performed by aPPO Provider, Premier Provider and a Non-Delta Dental Provider. However, the amount charged to Enrollees forcovered services performed by a Premier Provider or Non-Delta Dental Provider may be above that accepted byPPO Providers, and Enrollees will be responsible for balance billed amounts.

3Waiting Periods are calculated for each Adult Enrollee from the effective date of coverage reported by the Exchangefor said Adult Enrollee. Prior coverage for Adult Enrollees under any Delta Dental Exchange plan that included anadult Waiting Period will be credited towards the adult Waiting Period under this dental plan. In order for priorcoverage to be credited, such prior coverage must occur immediately preceding the election of this plan.

4Benefits are not provided for orthodontic treatment including all services related to orthodontic treatment (such asdiagnostic and pre-treatment records) until the 12 month Waiting Period is satisfied. Waiting Periods arecalculated for each Pediatric Enrollee from the effective date of coverage reported by the Exchange for saidPediatric Enrollee. Prior coverage for Pediatric Enrollees under a Delta Dental exchange certified pediatricessential dental plan will be credited towards the pediatric Waiting Period under this dental plan. In order for priorcoverage to be credited, such prior coverage must occur immediately preceding the election of this plan.


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XIAtBhi-DC-ENT-15 1

Attachment BServices, Limitations and Exclusions

D e s c rip t io n o f D e n tal S e rv ic e s fo r A d u lt B e n e fi ts (ag e 1 9 a n d o ld e r) Delta Dental will pay or otherwise discharge the Policy Benefit Level shown in Attachment A for the followingservices:

Diagnostic and Preventive Services(1) Diagnostic: procedures to aid the Provider in determining required dental

treatment.

(2) Preventive: cleaning (periodontal cleaning in the presence of inflamed gums isconsidered to be a Basic Service for payment purposes).

(3) SpecialistConsultations:

opinion or advice requested by a general dentist.

Basic Services(1) General Anesthesia

or IV Sedationwhen administered by a Provider for covered Oral Surgery orselected endodontic and periodontal surgical procedures.

(2) PeriodontalCleanings:

periodontal maintenance.

(3) Palliative: emergency treatment to relieve pain.

(4) Restorative: amalgam and resin-based composite restorations (fillings) andprefabricated stainless steel restorations for treatment of cariouslesions (visible destruction of hard tooth structure resulting from theprocess of decay).

Major Services(1) Crowns and

Inlays/Onlays:treatment of carious lesions (visible decay of the hard tooth structure)when teeth cannot be restored with amalgam or resin-basedcomposites.

(2) Prosthodontics: procedures for construction of fixed bridges, partial or completedentures and the repair of fixed bridges; implant surgical placementand removal; and for implant supported prosthetics, including implantrepair and recementation.

(3) Oral Surgery: extractions and certain other surgical procedures (including pre-andpost-operative care).

(4) Endodontics: treatment of diseases and injuries of the tooth pulp.

(5) Periodontics: treatment of gums and bones supporting teeth.

(6) Denture Repairs: repair to partial or complete dentures, including rebase procedures andrelining.

N o t e o n a d d i t io n a l B e n e f i t s d u r i n g p r e g n an c y When an Enrollee is pregnant, Delta Dental will pay for additional services to help improve the oral healthof the Enrollee during the pregnancy. The additional services each Calendar Year while the Enrollee iscovered under the Policy include one (1) additional oral exam and either one (1) additional routinecleaning; one (1) additional periodontal scaling and root planing per quadrant; or one (1) additionalperiodontal maintenance procedure. Written confirmation of the pregnancy must be provided by theEnrollee or her Provider when the claim is submitted.

L imita t io n s fo r A d u lt B e n e fi ts (a g e 19 a n d o ld e r) (1) Services that are more expensive than the form of treatment customarily provided under accepted dentalpractice standards are called Optional Services. Optional Services also include the use of specializedtechniques instead of standard procedures.

Examples of Optional Services:a) a composite restoration instead of an amalgam restoration on posterior teeth;b) a crown where a filling would restore the tooth;c) an inlay/onlay instead of an amalgam restoration; ord) porcelain, resin or similar materials for crowns placed on a maxillary second or third molar, or on any

mandibular molar (an allowance will be made for a porcelain fused to high noble metal crown).


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XIAtBhi-DC-ENT-15 2

If an Enrollee receives Optional Services, an alternate Benefit will be allowed, which means Delta Dentalwill base Benefits on the lower cost of the customary service or standard practice instead of on the highercost of the Optional Service. The Enrollee will be responsible for the difference between the higher cost ofthe Optional Service and the lower cost of the customary service or standard procedure.

(2) Delta Dental will pay for oral examinations (except after hours exams and exams for observation) no morethan twice in a Calendar Year.

(3) Delta Dental will pay for cleanings (including periodontal cleanings in the presence of inflamed gums or anycombination thereof) no more than twice in a Calendar Year.A full mouth debridement is allowed once in alifetime and counts toward the cleaning frequency in the year provided. Note that periodontal cleanings and

full mouth debridement are covered as a Basic Benefit, and routine cleanings are covered as a Diagnosticand Preventive Benefit. See note on additional Benefits during pregnancy.

(4) X-ray limitations:a) Delta Dental will limit the total reimbursable amount to the Providers Accepted Fee for a complete

intraoral series when the fees for any combination of intraoral x-rays in a single treatment series meetor exceed the Accepted Fee for a complete intraoral series.

b) When a panoramic film is submitted with supplemental film(s), Delta Dental will limit the totalreimbursable amount to the Providers Accepted Fee for a complete intraoral series.

c) If a panoramic film is taken in conjunction with an intraoral complete series, Delta Dental considers thepanoramic film to be included in the complete series.

d) A complete intraoral series and panoramic film are each limited to once every 60 months.e) Bitewing x-rays are limited to one (1) time each Calendar Year. Bitewings of any type are disallowed

within 12 months of a full mouth series unless warranted by special circumstances.

(5) Pulp vitality tests are allowed once per day when definitive treatment is not performed.(6) Specialist Consultations are limited to once per lifetime per Provider and count toward the oral exam

frequency.

(7) Delta Dental will not cover to replace an amalgam, resin-based composite or prefabricated resin andstainless steel crowns within 24 months of treatment if the service is provided by the sameProvider/Provider office. Replacement restorations within 24 months are included in the fee for the originalrestoration.

(8) Protective restorations (sedative fillings) are allowed once per tooth per lifetime when definitive treatment isnot performed on the same date of service.

(9) Therapeutic pulpotomy is limited to once per lifetime for baby (deciduous) teeth only and is consideredpalliative treatment for permanent teeth.

(10)Root canal therapy and pulpal therapy (resorbable filling) are limited to once in a lifetime. Retreatment ofroot canal therapy by the same Provider/Provider office within 24 months is considered part of the originalprocedure.

(11)Retreatment of apical surgery by the same Provider/Provider office within 24 months is considered part ofthe original procedure.

(12)Pin retention is covered not more than once in any 24-month period.

(13)Palliative treatment is covered per visit, not per tooth, and the fee includes all treatment provided other thanrequired x-rays or select Diagnostic procedures.

(14)Periodontal limitations:a) Benefits for periodontal scaling and root planing in the same quadrant are limited to once in every 24-

month period. See note on additional Benefits during pregnancy.

b) Periodontal surgery in the same quadrant is limited to once in every 36-month period and includes anysurgical re-entry or scaling and root planing.

c) Periodontal services, including bone replacement grafts, guided tissue regeneration, graft proceduresand biological materials to aid in soft and osseous tissue regeneration are only covered for thetreatment of natural teeth and are not covered when submitted in conjunction with extractions,periradicular surgery, ridge augmentation or implants.

d) If in the same quadrant, scaling and root planing must be performed at least six (6) weeks prior to theperiodontal surgery.

e) Cleanings (regular and periodontal) and full mouth debridement are subject to a 30 day wait followingperiodontal scaling and root planing if performed by the same Provider office.

(15)Oral Surgery services are covered once in a lifetime except removal of cysts and lesions and incision anddrainage procedures, which are covered once in the same day.


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XIAtBhi-DC-ENT-15 3

(16)Crowns and Inlays/Onlays are covered not more often than once in any 60 month period except whenDelta Dental determines the existing Crown or Inlay/Onlay is not satisfactory and cannot be madesatisfactory because the tooth involved has experienced extensive loss or changes to tooth structure orsupporting tissues.

(17)When an alternate Benefit of an amalgam is allowed for inlays/onlays, they are covered not more than oncein any 60 month period.

(18)Core buildup, including any pins, are covered not more than once in any 60 month period.

(19)Post and core services are covered not more than once in any 60 month period.

(20)Crown repairs are covered not more than once in any 60 month period.

(21)When allowed within six (6) months of a restoration, the Benefit for a Crown, Inlay/Onlay or fixedprosthodontic service will be reduced by the Benefit paid for the restoration.

(22)Denture Repairs are covered not more than once in any six (6) month period except for fixed DentureRepairs which are covered not more than once in any 60 month period.

(23)Prosthodontic appliances implants and/or implant supported prosthetics that were provided under any DeltaDental program will be replaced only after 60 months have passed, except when Delta Dental determinesthat there is such extensive loss of remaining teeth or change in supporting tissue that the existing fixedbridge or denture cannot be made satisfactory. Replacement of a prosthodontic appliance and/or implantsupported prosthesis not provided under a Delta Dental program will be made if Delta Dental determines itis unsatisfactory and cannot be made satisfactory. Diagnostic and treatment facilitating aids for implantsare considered a part of, and included in, the fees for the definitive treatment. Delta Dentals payment forimplant removal is limited to one (1) for each implant during the Enrollees lifetime whether provided underDelta Dental or any other dental care plan.

(24)When a posterior fixed bridge and a removable partial denture are placed in the same arch in the sametreatment episode, only the partial denture will be a Benefit.

(25)Recementation of Crowns, Inlays/Onlays or bridges is included in the fee for the Crown, Inlay/Onlay orbridge when performed by the same Provider/Provider office within six (6) months of the initial placement.

After six (6) months, payment will be limited to one (1) recementation in a lifetime by the sameProvider/Provider office.

(26)The initial installation of a prosthodontic appliance and/or implants is not a Benefit unless the prosthodonticappliance and/or implant, bridge or denture is made necessary by natural, permanent teeth extractionoccurring during a time the Enrollee was under a Delta Dental plan.

(27)Delta Dental limits payment for dentures to a standard partial or complete denture (Enrollee Coinsurancesapply). A standard denture means a removable appliance to replace missing natural, permanent teeth thatis made from acceptable materials by conventional means and includes routine post delivery care includingany adjustments and relines for the first six (6) months after placement.a) Denture rebase is limited to one (1) per arch in a 24-month period and includes any relining and

adjustments for six (6) months following placement.b) Dentures, removable partial dentures and relines include adjustments for six (6) months following

installation. After the initial six (6) months of an adjustment or reline, adjustments are limited to two (2)per arch in a Calendar Year and relining is limited to one (1) per arch in a six (6) month period.

c) Tissue conditioning is limited to two (2) per arch in a 12-month period. However, tissue conditioning isnot allowed as a separate Benefit when performed on the same day as a denture, reline or rebaseservice.

d) Recementation of fixed partial dentures is limited to once in a lifetime.

E x c lu s io n s fo r A d u lt B e n e fi ts (ag e 1 9 an d o ld e r) Delta Dental does not pay Benefits for:(1) treatment of injuries or illness covered by workers compensation or employers liability laws; services

received without cost from any federal, state or local agency, unless this exclusion is prohibited by law.

(2) cosmetic surgery or procedures for purely cosmetic reasons.

(3) maxillofacial prosthetics.

(4) provisional and/or temporary restorations.


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XIAtBhi-DC-ENT-15 4

(5) services for congenital (hereditary) or developmental (following birth) malformations, including but notlimited to cleft palate, upper and lower jaw malformations, enamel hypoplasia ( lack of development),fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except thoseservices provided to newborn children for medically diagnosed congenital defects or birth abnormalities.

(6) treatment to stabilize teeth, treatment to restore tooth structure lost from wear, erosion, or abrasion ortreatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion. Examplesinclude but are not limited to: equilibration, periodontal splinting, complete occlusal adjustments or NightGuards/Occlusal guards and abfraction.

(7) any Single Procedure provided prior to the date the Enrollee became eligible for services under this plan.

(8) prescribed drugs, medication, pain killers, antimicrobial agents, or experimental/investigational procedures.

(9) charges for anesthesia, other than General Anesthesia and IV Sedation administered by a Provider inconnection with covered Oral Surgery or selected endodontic and periodontal surgical procedures.

(10)extraoral grafts (grafting of tissues from outside the mouth to oral tissues).

(11)interim implants.

(12)indirectly fabricated resin-based Inlays/Onlays.

(13)charges by any hospital or other surgical or treatment facility and any additional fees charged by theProvider for treatment in any such facility.

(14)treatment by someone other than a Provider or a person who by law may work under a Providers directsupervision.

(15)charges incurred for oral hygiene instruction, a plaque control program, preventive control programsincluding home care times, dietary instruction, x-ray duplications, cancer screening, tobacco counseling orbroken appointments are not separately payable procedures.

(16)dental practice administrative services including, but not limited to, preparation of claims, any non-treatmentphase of dentistry such as provision of an antiseptic environment, sterilization of equipment or infectioncontrol, or any ancillary materials used during the routine course of providing treatment such as cottonswabs, gauze, bibs, masks or relaxation techniques such as music.

(17)procedures having a questionable prognosis based on a dental consultants professional review of thesubmitted documentation.

(18)any tax imposed (or incurred) by a government, state or other entity, in connection with any fees chargedfor Benefits provided under the Policy, will be the responsibility of the Enrollee and not a covered Benefit.

(19)Deductibles, amounts over plan maximums and/or any service not covered under the dental plan.

(20)services covered under the dental plan but exceed Benefit limitations or are not in accordance withprocessing policies in effect at the time the claim is processed.

(21)the initial placement of any prosthodontic appliance or implants, unless such placement is needed toreplace one or more natural, permanent teeth extracted while the Enrollee is covered under the Policy orwas covered under any dental care plan with Delta Dental. The extraction of a third molar (wisdom tooth)will not qualify under the above. Any such denture or fixed bridge must include the replacement of theextracted tooth or teeth.

(22)services for Orthodontic treatment (treatment of malocclusion of teeth and/or jaws) including orthodonticrelated services such as cephalometric x-rays, oral/facial photographic images and diagnostic casts,

surgical access of an unerupted tooth, placement of device to facilitate eruption of impacted tooth andsurgical repositioning of teeth.

(23)services for any disturbance of the temporomandibular (jaw) joints (TMJ) or associated musculature, nervesand other tissues).

(24)endodontic endosseous implant.

(25)services or supplies for sealants, fluoride, space maintainers, apexification and transseptalfiberotomy/supra crestal fiberotomy.


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XIAtBhi-DC-ENT-15 5

D e s c rip t io n o f D e n ta l S e rv ic e s fo r P e d iatr ic B e n e fi ts (u n d e r a g e 1 9 )Delta Dental will pay or otherwise discharge the Policy Benefit Level shown in Attachment A for EssentialHealth Benefits when provided by a Provider and when necessary and customary under generally accepteddental practice standards and for medically necessary Orthodontic Services. Orthodontic treatment is a benefitof this dental plan only when medically necessary as evidenced by a severe handicapping malocclusion andwhen a prior authorization is obtained. Severe handicapping malocclusion is not a cosmetic condition. Teethmust be severely misaligned causing functional problems that compromise oral and/or general health. Benefitsfor medically necessary orthodontics will be provided in periodic payments based on continued enrollment.

Diagnostic and Preventive Services(1) Diagnostic: procedures to aid the Provider in determining required dental

treatment.

(2) Preventive cleaning (periodontal cleaning in the presence of inflamed gums isconsidered to be a Basic Benefit for payment purposes), topicalapplication of fluoride solutions, space maintainers.

(3) Sealants: topically applied acrylic, plastic or composite materials used to sealdevelopmental grooves and pits in permanent molars for thepurpose of preventing decay.

(4) SpecialistConsultations:

opinion or advice requested by a general dentist.

Basic Services(1) General Anesthesiaor IV Sedation:

when administered by a Provider for covered Oral Surgery orselected endodontic and periodontal surgical procedures.

(2) PeriodontalCleanings:

periodontal maintenance.

(3) Palliative: emergency treatment to relieve pain.

(4) Restorative: amalgam and resin-based composite restorations (fillings) andprefabricated stainless steel restorations for treatment of cariouslesions (visible destruction of hard tooth structure resulting from theprocess of decay).

Major Services(1) Crowns and

Inlays/Onlays:

treatment of carious lesions (visible decay of the hard tooth structure)

when teeth cannot be restored with amalgam or resin-basedcomposites.

(2) Prosthodontics: procedures for construction of fixed bridges, partial or completedentures and the repair of fixed bridges; implant surgical placementand removal; and for implant supported prosthetics, including implantrepair and recementation.

(3) Oral Surgery: extractions and certain other surgical procedures (including pre-andpost-operative care).

(4) Endodontics: treatment of diseases and injuries of the tooth pulp.

(5) Periodontics: treatment of gums and bones supporting teeth.

(6) Denture Repairs: repair to partial or complete dentures, including rebase procedures andrelining.

(7) NightGuards/OcclusalGuards:

intraoral removable appliances provided for treatment of harmful oralhabits.

L imita t io n s fo r P e d ia tr ic B e n e fi ts (u n d e r a g e 1 9)(1) Services that are more expensive than the form of treatment customarily provided under accepted dental

practice standards are called Optional Services. Optional Services also include the use of specializedtechniques instead of standard procedures.


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XIAtBhi-DC-ENT-15 6

If an Enrollee receives Optional Services, an alternate Benefit will be allowed, which means Delta Dentalwill base Benefits on the lower cost of the customary service or standard practice instead of on the highercost of the Optional Service. The Enrollee will be responsible for the difference between the higher cost ofthe Optional Service and the lower cost of the customary service or standard procedure.

(2) Claims shall be processed in accordance with Delta Dentals standard processing policies. The processingpolicies may be revised from time to time; therefore, Delta Dental shall use the processing policies that arein effect at the time the claim is processed. Delta Dental may use dentists (dental consultants) to reviewtreatment plans, diagnostic materials and/or prescribed treatments to determine generally accepted dentalpractices and to determine if treatment has a favorable prognosis.

(3) If a primary dental procedure includes component procedures that are performed at the same time as theprimary procedure, the component procedures are considered to be part of the primary procedure forpurposes of determining the benefit payable under this Policy. If the Provider bills separately for the primaryprocedure and each of its component parts, the total benefit payable for all related charges will be limited tothe maximum benefit payable for the primary procedure.

(4) Delta Dental will pay for oral examinations (except after hours exams and exams for observation) no morethan once every six (6) months.

(5) Delta Dental will pay for routine cleanings no more than once every six (6) months. Periodontalmaintenance in the presence of inflamed gums are limited to four (4) times in a 12-month period. Up to four(4) periodontal maintenance procedures and up to two (2) routine cleanings not to exceed four (4)procedures or any combination thereof in a 12-month period. A full mouth debridement is allowed once in alifetime and counts toward the cleaning frequency in the year provided. Note that periodontal cleanings andfull mouth debridement are covered as a Basic Benefit, and routine cleanings are covered as a Diagnostic

and Preventive Benefit. Periodontal maintenance is only covered when performed following activeperiodontal therapy.

(6) X-ray limitations:a) Delta Dental will limit the total reimbursable amount to the Providers Accepted Fee for a complete

intraoral series when the fees for any combination of intraoral x-rays in a single treatment series meetor exceed the Accepted Fee for a complete intraoral series.

b) When a panoramic film is submitted with supplemental film(s), Delta Dental will limit the totalreimbursable amount to the Providers Accepted Fee for a complete intraoral series.

c) If a panoramic film is taken in conjunction with an intraoral complete series, Delta Dental considers thepanoramic film to be included in the complete series.

d) A complete intraoral series and panoramic film are each limited to once every 60 months.e) Bitewing x-rays are limited to once every six (6) months. Bitewings of any type are disallowed within 12

months of a full mouth series unless warranted by special circumstances.

(7) Cephalometric x-rays, oral/facial photographic images and diagnostic casts are covered only whenOrthodontic Services are covered. If Orthodontic Services are covered, see Orthodontic Limitations as agelimits may apply.

(8) Pulp vitality tests are allowed once per day when definitive treatment is not performed. The fee for pulpvitality tests are included in the fee for any definitive treatment performed on the same date.

(9) Caries risk assessments are limited to no more than once in a 36-month period and are a Benefit forEnrollees ages three (3) to 19.

(10)Topical application of fluoride solutions is limited to twice within a 12-month period.

(11)Space maintainer limitations:a) Space maintainers are limited to the initial appliance.b) Recementation of space maintainer is limited to once per lifetime.c) The removal of a fixed space maintainer is considered to be included in the fee for the space

maintainer; however, an exception is made if the removal is performed by a differentProvider/Providers office.

(12)Sealants are limited as follows:a) to permanent molars if they are without caries (decay) or restorations on the occlusal surface.b) do not include repair or replacement of a Sealant on any tooth within 36 months of its application.

(13)Specialist Consultations are limited to once per lifetime per Provider and count toward the oral examfrequency.

(14)Delta Dental will not cover to replace an amalgam or resin-based composite within 24 months of treatmentif the service is provided by the same Provider/Provider office. Prefabricated stainless steel crowns arelimited to once per Enrollee per tooth in any 60-month period. Replacement restorations within 24 monthsare included in the fee for the original restoration.


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(15)Protective restorations (sedative fillings) are allowed once per tooth per lifetime when definitive treatment isnot performed on the same date of service. The fee for protective restorations are included in the fee forany definitive treatment performed on the same date.

(16)Stainless steel crowns are allowed on baby (deciduous) teeth and permanent teeth up to age 16.

(17)Therapeutic pulpotomy is limited to once per lifetime for baby (deciduous) teeth only; an allowance for anemergency palliative treatment is made when performed on permanent teeth.

(18)Root canal therapy and pulpal therapy (resorbable filling) are limited to once in a lifetime. Retreatment of

root canal therapy by the same Provider/Provider office within 24 months is considered part of the originalprocedure.

(19)Apexification is only benefited on permanent teeth with incomplete root canal development or for the repairof a perforation. Apexification visits have a lifetime limit per tooth of one (1) initial visit, four (4) interim visitsand one (1) final visit.

(20)Retreatment of apical surgery by the same Provider/Provider office within 24 months is considered part ofthe original procedure.

(21)Pin retention is covered once per tooth in any 24-month period. Fees for additional pins on the same toothon the same date are considered a component of the initial pin placement.

(22)Palliative treatment is covered per visit, not per tooth, and the fee for palliative treatment provided inconjunction with any procedures other than x-rays or select Diagnostic procedures is considered included

in the fee for the definitive treatment.

(23)Periodontal limitations:a) Benefits for periodontal scaling and root planing in the same quadrant are limited to once in every 24-

month period.b) Periodontal surgery in the same quadrant is limited to once in every 36-month period and includes any

surgical re-entry or scaling and root planing.c) Periodontal services, including graft procedures are only covered for the treatment of natural teeth and

are not covered when submitted in conjunction with extractions, periradicular surgery, ridgeaugmentation or implants.

d) If in the same quadrant, scaling and root planing must be performed at least six (6) weeks prior to theperiodontal surgery.

e) Cleanings (regular and periodontal) and full mouth debridement are subject to a 30 day wait followingperiodontal scaling and root planing if performed by the same Provider office.

(24)Oral Surgery services are covered once in a lifetime except incision and drainage procedures, which arecovered once in the same day.

(25)Crowns and Inlays/Onlays are limited to Enrollees age 12 and older and are covered not more often thanonce in any 60 month period except when Delta Dental determines the existing Crown or Inlay/Onlay is notsatisfactory and cannot be made satisfactory because the tooth involved has experienced extensive loss orchanges to tooth structure or supporting tissues. Services will only be allowed on teeth that aredevelopmentally mature.

(26)When an alternate Benefit of an amalgam is allowed for inlays/onlays, they are limited to Enrollees age 12and older and are covered not more than once in any 60 month period. Services will only be allowed onteeth that are developmentally mature.

(27)Core buildup, including any pins, are covered not more than once in any 60 month period.

(28)Post and core services are covered not more than once in any 60 month period.

(29)Crown repairs are covered not more than once in any 60 month period.

(30)When allowed within six (6) months of a restoration, the Benefit for a Crown, Inlay/Onlay or fixedprosthodontic service will be reduced by the Benefit paid for the restoration.

(31)Denture Repairs are covered not more than once in any six (6) month period except for fixed DentureRepairs which are covered not more than once in any 60 month period.

(32)Prosthodontic appliances, implants and/or implant supported prosthetics (except for implant/abutmentsupported removable dentures) that were provided under any Delta Dental program will be replaced onlyafter 60 months have passed, except when Delta Dental determines that there is such extensive loss ofremaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made


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satisfactory. Fixed prosthodontic appliances are limited to Enrollees age 16 and older. Replacement of aprosthodontic appliance and/or implant supported prosthesis not provided under a Delta Dental programwill be made if Delta Dental determines it is unsatisfactory and cannot be made satisfactory. Services willonly be allowed on teeth that are developmentally mature. Diagnostic and treatment facilitating aids forimplants are considered a part of, and included in, the fees for the definitive treatment. Delta Dentalspayment for implant removal is limited to one (1) for each implant within a 60-month period whetherprovided under Delta Dental or any other dental care plan.

(33)An implant is a covered procedure of the plan only if determined to be a dental necessity. If an arch can berestored with a standard prosthesis or restoration, no benefits will be allowed for the individual implant orimplant procedures. Only the second phase of treatment (the prosthodontic phase-placing of the implant

crown, bridge denture or partial denture) may be subject to the alternate benefit provision of the plan.

(34)When a posterior fixed bridge and a removable partial denture are placed in the same arch in the sametreatment episode, only the partial denture will be a Benefit.

(35)Recementation of Crowns, Inlays/Onlays or bridges is included in the fee for the Crown, Inlay/Onlay orbridge when performed by the same Provider/Provider office within six (6) months of the initial placement.

After six (6) months, payment will be limited to one (1) recementation in a (6) month period by the sameProvider/Provider office.

(36)The initial installation of a prosthodontic appliance and/or implants is not a Benefit unless the prosthodonticappliance and/or implant, bridge or denture is made necessary by natural, permanent teeth extractionoccurring during a time the Enrollee was under a Delta Dental plan.

(37)Delta Dental limits payment for dentures to a standard partial or complete denture (Enrollee Coinsurances

apply). A standard denture means a removable appliance to replace missing natural, permanent teeth thatis made from acceptable materials by conventional means and includes routine post delivery care includingany adjustments and relines for the first six (6) months after placement.a) Denture rebase is limited to one (1) per arch in a 36-month period and includes any relining and

adjustments for six (6) months following placement.b) Dentures, removable partial dentures and relines include adjustments for six (6) months following

installation. After the initial six (6) months of an adjustment or reline, adjustments and relining arelimited to one (1) per arch in a 36-month period.

c) Tissue conditioning is limited to two (2) per arch in a 12-month period. However, tissue conditioning isnot allowed as a separate Benefit when performed on the same day as a denture, reline or rebaseservice.

d) Recementation of fixed partial dentures is limited to once in a lifetime.

(38)Occlusal guards are covered by report for Enrollees age 13 or older when the purpose of the occlusalguard is for the treatment of bruxism or diagnoses other than temporomandibular joint dysfunction (TMJD).

Occlusal guards are limited to one (1) per 12 consecutive month period. Delta Dental will not cover therepair or replacement of any appliances for Night Guard/Occlusal Guard.

(39)Limitations on Orthodontic Servicesa) Services are limited to medically necessary orthodontics when provided by a Provider and when

necessary and customary under generally accepted dental practice standards. Orthodontic treatment isa benefit of this dental plan only when medically necessary as evidenced by a severe handicappingmalocclusion and when a prior authorization is obtained.

b) Orthodontic procedures are a benefit only when the diagnostic casts verify a minimum score of 26points on the Handicapping Labio-Lingual Deviation (HLD) Index or one of the automatic qualifyingconditions below exist.

c) The automatic qualifying conditions are:i. Cleft palate deformity. If the cleft palate is not visible on the diagnostic casts written

documentation from a credentialed specialist shall be submitted, on their professionalletterhead, with the prior authorization request,ii. A deep impinging overbite in which the lower incisors are destroying the soft tissue of the

palate,iii. A crossbite of individual anterior teeth causing destruction of soft tissue,iv. Severe traumatic deviation.

d) The following documentation must be submitted with the request for prior authorization of services bythe Provider:

i. ADA 2006 or newer claim form with service code(s) requested;ii. Diagnostic study models (trimmed) with bite registration; or OrthoCad equivalent;

iii. Cephalometric radiographic image or panoramic radiographic image;iv. HLD score sheet completed and signed by the Orthodontist; andv. Treatment plan.


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e) The allowances for comprehensive orthodontic treatment procedures (D8080, D8090) include allappliances, adjustments, insertion, removal and post treatment stabilization (retention). No additionalcharge to the Enrollee is permitted.

f) Comprehensive orthodontic treatment includes the replacement, repair and removal of brackets, bandsand arch wires by the original Provider.

g) Orthodontic procedures are benefits for medically necessary handicapping malocclusion, cleft palateand facial growth management cases for Enrollees under the age of 19 and shall be prior authorized.

h) Only those cases with permanent dentition shall be considered for medically necessary handicappingmalocclusion, unless the Enrollee is age 13 or older with primary teeth remaining. Cleft palate andcraniofacial anomaly cases are a benefit for primary, mixed and permanent dentitions. Craniofacialanomalies are treated using facial growth management.

i) All necessary procedures that may affect orthodontic treatment shall be completed before orthodontictreatment is considered.

j) When specialized orthodontic appliances or procedures chosen for aesthetic considerations areprovided, Delta Dental will make an allowance for the cost of a standard orthodontic treatment. TheEnrollee is responsible for the difference between the allowance made towards the standardorthodontic treatment and the dentists charge for the specialized orthodontic appliance or procedure.

k) Repair and replacement of an orthodontic appliance inserted under this dental plan that has beendamaged, lost, stolen, or misplaced is not a covered service.

E x c lu s io n s fo r P e d ia tr ic B e n e fi ts (u n d e r a g e 1 9 )Delta Dental does not pay Benefits for:(1) services that are not Essential Health Benefits.

(2) treatment of injuries or illness covered by workers compensation or employers liability laws; servicesreceived without cost from any federal, state or local agency, unless this exclusion is prohibited by law.

(3) cosmetic surgery or procedures for purely cosmetic reasons.

(4) maxillofacial prosthetics.

(5) provisional and/or temporary restorations (except an interim removable partial denture to replace extractedanterior permanent teeth during the healing period for children 16 years of age or under).

(6) services for congenital (hereditary) or developmental (following birth) malformations, including but notlimited to cleft palate, upper and lower jaw malformations, enamel hypoplasia ( lack of development),fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except thoseservices provided to children for medically diagnosed congenital defects or birth abnormalities.

(7) treatment to stabilize teeth, treatment to restore tooth structure lost from wear, erosion, or abrasion ortreatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion. Examplesinclude but are not limited to: equilibration, periodontal splinting, or complete occlusal adjustments.

(8) any Single Procedure provided prior to the date the Enrollee became eligible for services under this plan.

(9) prescribed drugs, medication, pain killers, antimicrobial agents, or experimental/investigational procedures.

(10)charges for anesthesia, other than general anesthesia and IV sedation administered by a Provider inconnection with covered oral surgery or selected endodontic and

Delta Dental Plan

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Transcript of Delta Dental Plan