TRUST YOUR SMILE TO

DELTA DENTAL2017/2018 Open EnrollmentCounty of San Bernardino Retirees

I. Your Dental Plans Effective 1/1/2018

- DeltaCare USA Program (pre-paid DHMO)

- Delta Dental PPO Program

- What’s NEW for 2018

- Additional PPO option

- Cost Estimator

II. Wellness Benefits

III. Questions

WHAT WE’LL COVER

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To enroll, complete and submit a County of San Bernardino Retiree Dental Plan Enrollment/ Change Form and submit to EBSD by mail or fax at:

Employee Benefits and Services Division157 West Fifth Street, First FloorSan Bernardino, CA 92415-0440Fax: 909-387-5566 Attn: Retiree Desk

1. You are eligible to enroll as an Enrollee/Dependent if you meet the eligibility requirements defined by the County of San Bernardino.

2. By electing retiree dental, retiree agrees to remain enrolled for a minimum of 24 consecutive months subject to:

• Retirees electing either the DHMO or Low DPPO plans can switch between the DHMO and the Low DPPO at annual Open Enrollment .

• Retirees electing the High DPPO beginning 1/1/2018 must remain enrolled in the High DPPO for 24 consecutive months, through 12/31/2019.

3. The 24 month enrollment requirement is offset for all prior months an enrollee has been continuously covered under a retiree dental plan.

4. Retirees wishing to cancel dental coverage at annual Open Enrollment are only eligible to do so after achieving 24 months continuous dental coverage.

24 Month Enrollment Required

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• For the Low Dental PPO and High Dental PPO plans only, a 12-month

waiting period for Class III (major restorative) services is applicable to any

County retiree who incurs a gap in coverage.

1. The waiting period is waived for any retiree and covered dependent that remains continuously covered when transitioning from active to retiree dental coverage.

2. Retirees who previously had COBRA benefits but did not re-enroll (resulting in a gap in coverage) are subject to the dental waiting period.

PPO – New Entrant Waiting Period

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DENTAL HEALTH QUIZ

How often should you replace your toothbrush?

Every 3 weeks

Once a year Once every 2 years

Every 3 months

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DENTAL HEALTH QUIZ

Replacing your toothbrush every 3 months prevents the growth of cold-causing bacteria and viruses

Every 3 weeks

Once a year Once every 2 years

Every 3 months

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DELTACARE®

USA

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Select a dentist Schedule

an appointmentReceive care

Pay

only your

copayment

GETTING STARTED IS EASYDeltaCare® USA

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Predictable costs• Pay only your copay (if any)• Enjoy no deductibles• Don’t worry about maximums

No claim forms

Minimal limitations and exclusions

Out-of-area emergency allowance

Specialty care with referral

Choice of your own network dentist

WE’VE GOT YOU COVERED

COVEREDPROCEDURES

300+

DeltaCare® USA

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NEED A SPECIALIST?

Visit your primary care dentist

Your dentist requests authorization for specialty services

You receive a referral to a specialist from your primary care dentist

DeltaCare® USA

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ORTHODONTICSDeltaCare® USA

All phases

Children and adults

Pre- and post- records

Tooth extractions

Treatment in progress coverage

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DeltaCare® USA

CHOOSE A DENTIST

Choose your own network dentist

Submit a County of San Bernardino Retiree Dental Plan

Enrollment/ Change Form and submit to EBSD by mail or fax

Changes throughout the year can be made:

Visit deltadentalins.com, log-in to enrollee portal to change your

network dentist online

Call Customer Service at 855-244-7323

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DELTA DENTAL PPOSM

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YOUR SMILE IS COVEREDwith Delta Dental PPOSM

Maximize your savings with a PPO dentist

When you visit a Delta Dental contracted dentist:

• No claim form

• You won’t be charged more than your expected share of the bill

See any licensed dentist

We’ll coordinate dual coverage

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WHAT’S NEWPPO PLAN SUMMARY

• Diagnostic & Preventive services will no longer be counted against your Annual Maximum.• Member gains additional $300 to $500 in annual benefit when receiving exams, x-rays and cleanings.

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Enhanced benefit for 1/1/2018!

New plan option for 1/1/2018!

Service Category IN-NETWORK NON-NETWORK IN-NETWORK NON-NETWORK

Reimbursement Basis PPO FeePremier Fee or

80th UCRPPO Fee

Premier Fee or

80th UCR

Calendar Year Maximum and Deductible

Annual Maximum $1,000 $1,000 $1,700 $1,700

Diagnostic & Preventive Waived Annual Maximum Yes Yes Yes Yes

Annual Deductible (per Patient / per Family) $50/$150 $50/$150 $50/$150 $50/$150

Diagnostic & Preventive Waived Annual Deductible Yes Yes Yes Yes

Annual Deductible $50/$150 $50/$150 $50/$150 $50/$150

Coinsurance

Diagnostic & Preventive 100% 70% 100% 100%

Basic Restorative Services 80% 60% 100% 90%

Endodontics 80% 60% 100% 90%

Periodontics 80% 60% 100% 90%

Oral Surgery 80% 60% 100% 90%

Major Restorative Services 50% 50% 75% 70%

Implants N/A* N/A* 75% 70%

* Low PPO plan covers prosthesis over implant.

LOW PPO HIGH PPO

THE CHOICE IS YOURSSave the most with PPO

Claims Example

Most claims savings Some claims savings No claims savings

In-Network

Delta Dental PPOOut-of-Network

Delta Dental Premier

Out-of-Network

Non-Delta Dental

Dentists

Dentist’s Charge for

a Crown $1,200 $1,200 $1,200

Plan Allowance $700 $900 $950

Percentage Paid by Plan 50% 50% 50%

Plan Payment $350 $450 $475

PATIENT PAYMENT$350

($700 - $350 =)

$450

($900 - $450 =)

$725

($1,200 - $475 =)

Note: Amounts listed for illustrative purposes only. Assumes no maximum or deductibles are applicable.

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PPO DUAL NETWORKADVANTAGE1 product — 2 levels of savings

25-35% average discount

8-16% average discount

Premier NetworkPPO Network

IN NETWORK OUT-OF-NETWORK

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We’ve got you coveredPRE-TREATMENT ESTIMATE

Determines costs ahead

of timeHelps you

make informed decisions Everything is

handled by your dentist

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TRANSITION OF CAREWhat if I’m in the middle of dental work?

Coverage begins on your effective date

There are no exclusions for pre-existing conditions or missing teeth

Treatment started before 1/1/2018 will continue to be covered by CIGNA. For example:

• Root canals• Crowns• Fixed bridges and partial dentures

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TRANSITION OF CAREOrthodontia

PPO: Orthodontia is not a covered benefit.

DHMO: Within 30 days, submit your “Continuous Orthodontist Coverage Form” to continue treatment with your current orthodontist.

Contact customer service for assistance at 855-244-7323

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Less paper, more convenience

Conserve natural resources

Download or print documents

Access your plan information with ease and convenience

Visit deltadentalins.com/paperless

GO PAPERLESS

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Sign up for an

www.deltadentalins.com

Locate a network dentist

Check benefits and eligibility

Check claim status

Dental education resources

View or print your ID card

ONLINE ACCOUNT

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FIND A DENTIST ONLINEIt’s simple!

Go to deltadentalins.com and log in

Select “Find a Dentist”

Delta Dental PPO

DeltaCare USA

Search by name, address, landmark, city or ZIP code

Get a map and driving directions

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COST ESTIMATOR (PPO ONLY)Get a customized cost estimate

PersonalizedBased on your benefits, including the current status of maximums and deductibles

Easy to useSimple questions to guide you through the process

Based on real dataCalculated from your actual processed claims and updated daily

Available on desktop and mobile

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YOU’RE MOBILEand so are we!

Use the mobile site to:

Access your ID card

Check eligibility, benefits and claims

Find a dentist by your location

Manage your profile

Or, get the free app and you can also:

Get a cost estimate (PPO only)

Use a musical tooth brushing timer

Get the app from the App Store or Google PlayTM

Search for “Delta Dental”

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WELLNESS BENEFITS

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WELLNESS BENEFITSFor enrollees, spouses and dependent children with one of the following chronic inflammation-related medical conditions

PPO 100% coverage for one periodontal scaling and root planing procedure per quadrant per

calendar year (D4341 or D4342)

Four of the following (any combination) per calendar year:

Prophylaxis (teeth cleaning; D1110 or D1120), covered at 100%

Periodontal maintenance procedure (D4910) covered at 100%

Opt-in/sign-up for the Smileway Wellness Benefit on the benefits area of the Enrollee Portal

Additional services available to pregnant women are available outside the wellness benefits

Heart Disease

Stroke

Rheumatoid Arthritis

Diabetes

HIV/AIDS

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WELLNESS BENEFITS (CONTINUED)DHMO Frequency limitations and copayment (D1110, D1120, D4910) will be waived when

services are needed more frequently due to medical necessity as determined by the Contract Dentist

Enrollees will be charged the standard copay for additional cleanings that exceed two in a calendar year

For reimbursement, the enrollee must submit a copy of the network dentist’s billing statement, proof of payment and written verification of the qualifying medical condition

Delta Dental will update the enrollee’s record to show the additional benefit is approved; future medical verification will not be required

Delta Dental will mail a refund check to the enrollee

Pregnancy is a covered condition under the DHMO plan

Refund requests should be mailed to:DeltaCare USA – Account Services

Group 78853 Refund

17871 Park Plaza Drive, Suite 200

Cerritos, CA 90703

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24/7 online access to benefits and eligibility

Dedicated Customer Service Number

855-244-7323

Nominate a provider to contract with

Delta Dental

www.deltadentalins.com

ABOUT YOUOur service is all

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DENTAL HEALTH QUIZ

If you don’t floss, how much of a tooth’s surface is left unclean?

10 percent

25 percent 35 percent

18 percent

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DENTAL HEALTH QUIZ

According to the Centers for Disease Control, 35 percent of tooth surfaces are left unclean if regular brushing is not accompanied by flossing.

10 percent

25 percent 35 percent

18 percent

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We’re pleased to take your questions…

THANK YOU FORYOUR TIME

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