Delta Dental Plan of Oregon - Individual & family Dental plans Oregon 2020 - Moda Health
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2021 | Delta Dental Plan of Oregon
Oregon 2020
Individual & family Dental plans
Welcome to
Delta Dental
Table of contents
of Oregon Plan overview . . . . . . . . . . . . . . .5
Coverage options . . . . . . . . . . . . .6
This is the place you come when you want
Benefit tables . . . . . . . . . . . . . . .7
more than a dental plan — because a healthy
smile and better overall health is about so Member care resources . . . . . . . . . 8
much more than just the plan details. Glossary . . . . . . . . . . . . . . . . . 10
Plan overview
Quality
coverage
for your smile
Healthy teeth are happy teeth. With the Delta Dental of
Oregon plan, you’ll have access to quality in-network
dentists.
Dental benefit highlights Tools for better oral health
Our Delta Dental of Oregon Once you are an active member,
plan connects you with great log in to your Member Dashboard
benefits. You can count on: and look for Dental Tools. Try
• No waiting periods for out tools available to you like the
preventive care risk assessment, quizzes and a
treatment cost calculator. Use these
• Savings from in- dental tools to:
network dentists
• Cleanings twice a year • Ask a dentist questions
• Predetermination of • Learn about preventing
dental diseases
benefits if requested
• Fast and accurate • Look up new and
effective treatments
claims payment
• Superior customer service • Find out how to
lower your costs
Our dental plan also includes
useful online tools, resources and
special programs for those of
you who may need a little extra
attention for your pearly whites.
4 5Delta Dental of Oregon
Coverage options
Subject to
Dental plan benefits and rates balance billing
Delta Dental networks Providers/Network
Premier and PPO
Delta Dental providers
Non-participating
providers1
go wherever you go Member pays
$25 per individual (deductible waived
Calendar year deductible
for preventive services)
The Delta Dental of Oregon plan comes with the Delta Dental network. Calendar year
$1,500 per individual2
It includes thousands of dentists with statewide and national access. benefit maximum
You can access the Delta Dental PPO or Delta Dental Premier network Preventive care available twice in a calendar year
with your plan. However, your benefit dollar goes further on the Delta Exams Covered in full2 Covered in full2
Dental PPOTM Network.
Cleanings Covered in full2 Covered in full2
Diagnostic Covered in full2, 3 Covered in full2, 3
Delta Dental Save when you
Premier ® Network stay in network Basic services
• Broader choice of providers In-network dentists agree to Restorative 20% after deductible4 20% after deductible4
• The largest dental network accept our contracted fees as full
Oral surgery (extractions) 20% after deductible4 20% after deductible4
nationally and one of the payment, which means they don’t
largest in Oregon balance bill. This can help you save
Endodontic/periodontic 20% after deductible4 20% after deductible4
on out-of-pocket costs. If you see
• Access to more than 2,400
providers outside the network,
providers in Oregon and over Major services
155,000 dentists nationwide you may pay more for care.
Crowns 50% after deductible4 50% after deductible4
Delta Dental PPOTM Network Cast restorations 50% after deductible4 50% after deductible4
• More cost control
Dentures/bridge work 50% after deductible4 50% after deductible4
• One of the largest PPO
networks in Oregon Implants 50% after deductible4 50% after deductible4
and nationwide
• Access to more than 1,300 Worldwide for emergency Worldwide for emergency
Out-of-area coverage
participating dentists in services only4 services only
Oregon and over 113,000
dentists nationwide This is a summary of benefits only, for general comparison. Any errors or omissions
are purely unintentional. Should any discrepancies be found between this guide and
the health plan document, the information in the health plan document shall prevail.
1
For non-participating providers, the maximum amount is based on the
PPO fee allowable. Non-participating providers may balance bill.
How do I find a dentist 2
Charges for preventive services do not apply to the calendar year benefit maximum.
in the network? 3
Some limitations apply.
To find a participating
4
There is a 12-month waiting period for basic and major services following enrollment
dentist in your area, unless member has had continuous employer-sponsored dental coverage for
visit Find Care on the previous 12 months immediately preceding PHIP dental enrollment.
modahealth.com/pers. Please note that there are some common limitations and exclusions for our 2021
Delta Dental of Oregon plan. For a full list of limitations and exclusions, please see
your member handbook.
6 7Member care resources
Tools for your
health journey
The Delta Dental of Oregon plan comes with tools and resources
to help you manage your oral health and well-being. Using
your personal Member Dashboard you can find dentists in
your network, view your explanation of benefits and more.
Once you are an active member, use these care resources to
help you be your healthy best! Simply log in to your Member
Dashboard at modahealth.com/pers to get started.
Cost Calculator Oral Health, Total Health Ask a dentist Health through Oral Wellness®
Learn the cost of dental care Seeing your dentist on a regular Ask questions and get guidance Delta Dental offers extra benefits
before the bill arrives. The basis and keeping your mouth or treatment for any non- and related care to members
Cost Calculator offers you a healthy is critical to keeping urgent illness or health concern. who have a greater risk for oral
simple way to understand: the rest of your body healthy. Board-certified dentists are diseases. Based on a risk score,
• Procedure costs This program offers individuals available to communicate members may qualify for enhanced
diagnosed with diabetes additional with you online for free for: dental benefits that include:
• Cost comparisons cleanings throughout the year.
across providers • Advice about non- • Additional cleanings
To find out more, contact our critical dental issues
• Your specific out-of- dental customer service.
• Fluoride treatments
pocket costs • Guidance about treatment • Sealants
Use this tool to shop for cost- • Answers to oral • Periodontal maintenance
effective alternatives and make health questions
better, well-informed decisions.
8 9Nondiscrimination notice
Glossary
We follow federal civil rights laws. ATENCIÓN: Si habla español, 注意：日本語をご希望の方には、 日本語
We do not discriminate based hay disponibles servicios de サービスを無料で提供しております。
on race, color, national origin, ayuda con el idioma sin costo 1-877-605-3229（TYY、テレタイプラ
age, disability, gender identity, alguno para usted. Llame al イターをご利用の方は711） までお電話
Healthcare sex or sexual orientation.
We provide free services to people
1-877-605-3229 (TTY: 711).
CHÚ Ý: Nếu bạn nói tiếng Việt, có
ください。
અગત્યનું: જો તમે (ભાષાંતર કરેલ ભાષા અહી ં
lingo explained
with disabilities so that they can dịch vụ hổ trợ ngôn ngữ miễn phí દર્શાવો) બોલો છો તો તે ભાષામાં તમારે માટે વિના
communicate with us. These include cho bạn. Gọi 1-877-605-3229 (TTY:711) મૂલ્યે સહાય ઉપલબ્ધ છે . 1-877-605-3229
sign language interpreters and (TTY: 711) પર કૉલ કરો
other forms of communication. 注意：如果您說中文，可得到免費
語言幫助服務。請致電 ໂປດຊາບ: ຖ້້ າທ່່ ານເວົ້�້ າພາສາລາວ,
If your first language is not English, we 1-877-605-3229（聾啞人專用：711） ການຊ່່ ວຍເຫຼື� ື ອດ້້ ານພາສາແມ່່ ນມີີໃຫ້້
will give you free interpretation services ທ່່ ານໂດຍບໍ່່�ເສັັຍຄ່່ າ. ໂທ
Balance billing Maximum plan and/or materials in other languages. 주의: 한국어로 무료 언어 지원 1-877-605-3229 (TTY: 711)
Charges for out-of-network care allowance (MPA) If you need any of the above,
서비스를 이용하시려면 다음
연락처로 연락해주시기 바랍니다. УВАГА! Якщо ви говорите
beyond what your dental plan MPA is the maximum amount call Customer Service at: 전화 1-877-605-3229 (TTY: 711) українською, для вас доступні
allows. Out-of-network providers that we will reimburse providers. безкоштовні консультації рідною
may bill members the difference 888-217-2365 (TDD/TTY 711) PAUNAWA: Kung nagsasalita ka мовою. Зателефонуйте
A non-contracted provider may ng Tagalog, ang mga serbisyong 1-877-605-3229 (TTY: 711)
between the maximum plan bill a member for any amount If you think we did not offer tulong sa wika, ay walang bayad,
allowance and their billed charges. over and above the MPA. This these services or discriminated, at magagamit mo. Tumawag sa ATENȚIE: Dacă vorbiți limba română, vă
In-network providers don’t do may leave members with a you can file a written complaint. numerong 1-877-605-3229 punem la dispoziție serviciul de asis-
this for covered services. high out-of-pocket balance.
Please mail or fax it to: (TTY: 711) tență lingvistică în mod gratuit. Sunați la
1-877-605-3229 (TTY 711)
Delta Dental of Oregon and Alaska فهناك خدمات، إذا كنت تتحدث العربية:تنبيه
Calendar year Out-of-pocket costs Attention: Appeal Unit اتصل برقم.مساعدة لغوية متاحة لك مجانًا THOV CEEB TOOM: Yog hais tias koj
benefit maximum What members pay in a
601 SW Second Ave.
Portland, OR 97204
)711 : (الهاتف النصي1-877-605-3229 hais lus Hmoob, muaj cov kev pab
cuam txhais lus, pub dawb rau koj. Hu
The maximum dollar amount a calendar year for care after their ارگ آپ اردو:�د( وتہج یURDU) �وبےتل ہ ي
Fax: 503-412-4003 ن ت rau 1-877-605-3229 (TTY: 711)
dental plan will pay toward the cost dental plan pays its portion. ل تالب اعموہضوت اسلین ااع� آپ ےک ی
If you need help filing a complaint, دساب ےہ۔ ی1-877-605-3229 (TTY: ត្រូ�ូវចងចាំំ៖ បើ�ើអ្ននកនិិយាយភាសាខ្មែ�ែរ
of dental care within a calendar year. These expenses may include please call Customer Service. رپ اکل ی
711)�رک ហើ�ើយត្រូ�ូវការសេ�វាកម្មមជំំនួួយផ្នែ�ែក
deductibles, coinsurance for ភាសាដោ�យឥតគិិតថ្លៃ�ៃ គឺឺមានផ្ដដល់់ជូូន
Coinsurance covered expenses and cost of care You can also file a civil rights complaint ВНИМАНИЕ! Если Вы говорите по- លោ�កអ្ននក។ សូូមទូូរស័័ព្ទទទៅ�កាន់់លេ�ខ
after the calendar year benefit with the U.S. Department of Health and русски, воспользуйтесь бесплатной 1-877-605-3229 (TTY: 711)
The percentage members pay for Human Services Office for Civil Rights at языковой поддержкой. Позвоните
a covered dental service after they maximum has been reached. ocrportal.hhs.gov/ocr/portal/lobby.jsf, по тел. 1-877-605-3229 (текстовый HUBACHIISA: Yoo afaan Kshtik
meet their deductible, if any. For or by mail or phone: телефон: 711). kan dubbattan ta’e tajaajiloonni
example, they may pay 20 percent PPO dentist gargaarsaa isiniif jira
U.S. Department of Health ATTENTION : si vous êtes locu- 1-877-605-3229 (TTY:711) tiin
of an allowed $200 charge, or $40. A dentist contracted in the Delta and Human Services teurs francophones, le service bilbilaa.
Dental PPOTM network. By choosing 200 Independence Ave. SW, Room 509F d’assistance linguistique gratuit
Deductible a PPO dentist, members’ out- HHH Building, Washington, DC 20201 est disponible. Appelez au โปรดทราบ: หากคุุณพููดภาษาไทย คุุณสามารถ
of-pocket expenses will be less. 1-877-605-3229 (TTY : 711) ใช้้บริิการช่่วยเหลืือด้้านภาษาได้้ฟรีี โทร
The amount members pay in a 800-368-1019, 800-537-7697 (TDD) 1-877-605-3229 (TTY: 711)
calendar year for care that requires As PPO dentists contract with در صورتی که به فارسی صحبت می:توجه
a deductible before the dental plan us at lower rates, the savings You can get Office for Civil Rights خدمات ترجمه به صورت رایگان برای،کنید FA’AUTAGIA: Afai e te tautala
can be passed on to you. complaint forms at hhs.gov/ 1-877-605-3229 با.شما موجود است i le gagana Samoa, o loo avanoa
starts paying. Disallowed charges ocr/office/file/index.html. .) تماس بگیریدTTY: 711( fesoasoani tau gagana mo
do not apply toward the deductible. oe e le totogia. Vala’au i le
Premier dentist Dave Nesseler-Cass coordinates our ध्यान दें: यदि आप हिदं ी बोलते हैं, तो 1-877-605-3229 (TTY: 711)
nondiscrimination work: आपको भाषाई सहायता बिना कोई पैसा
A dentist contracted with Delta Dave Nesseler-Cass,
Dental who has agreed that their
दिए उपलब्ध है। 1-877-605-3229 पर IPANGAG: Nu agsasaoka iti
Chief Compliance Officer कॉल करें (TTY: 711) Ilocano, sidadaan ti tulong iti
charges will not exceed their 601 SW Second Ave. lengguahe para kenka nga awan
contracted rate with Delta Dental. Portland, OR 97204 Achtung: Falls Sie Deutsch bayadna. Umawag iti
855-232-9111 sprechen, stehen Ihnen kostenlos 1-877-605-3229 (TTY: 711)
compliance@modahealth.com Sprachassistenzdienste zur Ver-
fügung. Rufen sie 1-877-605-3229 UWAGA: Dla osób mówiących
(TTY: 711) po polsku dostępna jest bezpłatna
pomoc językowa. Zadzwoń:
1-877-605-3229 (obsługa TTY: 711)
10 Dental plans in Oregon provided by Oregon Dental Service, dba Delta Dental 11
Plan of Oregon. Dental plans in Alaska provided by Delta Dental of Alaska.Questions? We’re here to help. Contact us toll free at 844-827-7379. TTY users, please call 711. modahealth.com/pers These benefits and Delta Dental policy are subject to change in order to be compliant with state and federal guidelines. Dental plans in Oregon provided by Delta Dental Plan of Oregon. 0601 (08/20)
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