Individual & family - Individual & family Dental plans Oregon 2020 - Moda Health
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2020 | Oregon dental plans
Individual & family
Oregon 2020
Individual & family Dental plans
Welcome to Table of contents
Plan overview . . . . . . . . . . . . . . . . . . 5
Delta Dental Coverage options .
How to enroll .
. . . . . . . . . . . . . . . 6
. . . . . . . . . . . . . . . . . . 8
of Oregon Benefit tables . . . . . . . . . . . . . . . . . . 10
Plan Rates . . . . . . . . . . . . . . . . . . . . . 13
FAQs . . . . . . . . . . . . . . . . . . . . . . . . 14
This is the place you come when you want more
Glossary . . . . . . . . . . . . . . . . . . . . . . 16
than a dental plan — because good health is
about so much more than just the plan details. Limitations and exclusions . . . . . . . . . 17
Plan overview
Quality
coverage
for your smile
Healthy teeth are happy teeth. With our individual and family Delta Dental
of Oregon plans, you’ll have access to quality in-network dentists.
Dental benefit highlights Tools for better oral health
Our Delta Dental of Oregon plans connect To get started, visit DeltaDentalOR.com and
you with great benefits. You can count on: log in to your Member Dashboard account.
• No waiting periods for Class 1 services If you don’t have an account, you can create
• Savings from in-network dentists one. Look for Dental tools. Then try out tools
like risk assessment quizzes and a treatment
• Cleanings every six months cost calculator. Use these dental tools to:
• Predetermination of benefits if • Ask a dentist questions
requested in a pretreatment plan
• Learn about preventing dental diseases
• Fast and accurate claims payment • Look up new and effective treatments
• Superior customer service • Find out how to lower your costs
Our dental plans also include useful online
tools, resources and special programs
for members who need a little extra
attention for their pearly whites.
4 5
Coverage options
Choosing the plan
that’s right for you
We offer three types of dental plans. Getting the right Delta Dental networks
coverage for you and your family has never been easier. go where you go
Delta Dental PPOSM plan Delta Dental PPO Bright Smiles plan Each Delta Dental of Oregon plan comes with a
Delta Dental network. It includes thousands of
This plan offers a broad range of both This PPO plan is available for all individual dentists with statewide and national access.
services and providers. You receive in- members, but benefits only cover children
network benefits when seeing a Delta under age 19. You receive in-network In-network dentists agree to accept our
Dental PPO Network dentist. For out-of- benefits when seeing a Delta Dental PPO contracted fees as full payment. This means
network benefits, you can save money by Network dentist. For out-of-network benefits, they don’t balance bill — the difference
seeing providers in the Delta Dental Premier you can save money by seeing providers between the allowed amount and the dentist’s
Network. In both cases, providers accept in the Delta Dental Premier Network. In billed charge. This can help you save on out-
the Delta Dental contracted fee, so there both cases, providers accept the Delta of-pocket costs. If you see providers outside
will be no additional balance billing charge. Dental contracted fee, so there will be the network, you may pay more for care.
no additional balance billing charge.
Delta Dental EPO plan Delta Dental PPO Network
This plan gives you a higher level of benefits This is one of the largest preferred provider
than the PPO plan, but you must see Delta organization (PPO) dental networks in
Dental PPO-contracted providers to receive Oregon and across the country. It includes
a benefit. This exclusive provider option more than 1,400 participating providers in
does not pay for services provided from Oregon and offers access to over 114,000
a Premier or non-contracted dentist. Care Delta Dental PPO dentists nationwide.
from providers outside this network is not
covered, except for emergency services.
Is my dentist in the network?
To find out, visit
modahealth.com/PPOdentists.
Choose a dental network
and look for participating
dentists in your area.
6 7How to enroll
Intro text goes here Ibea deribus velis adi inctota quam de cus, sam lantum
utassimusa sit dercia quia volorendem fugiatusam, omnis atqui diandit aspiet
ut pratust que saercidi blatus.Nequibeatur, simenem natis ra volupta quaectus,
que quo blaudi cum et et laceperovid mi, sum facepedis et aut quidercid est
Confirm Find the Enroll at
your eligibility plan you like ShopModaPlans.com H2 goes here
You must be an Oregon Browse and compare Starting Nov. 1, 2019, visit
Body copy goes here
resident and live in Oregon our 2020 dental plans ShopModaPlans.com to
at least six months out in this brochure or at enroll in 2020 Delta Dental
of the calendar year to ShopModaPlans.com. of Oregon dental plans.
be eligible to enroll. The website also explains If you qualify for federal
how health plans, financial assistance, we’ll
Eligible members include
healthcare reform and show you how to apply
you, your legal spouse or
federal financial assistance through the Marketplace,
domestic partner and any
work — so take a look! HealthCare.gov. If you
children up to age 26.
are also enrolling for
When deciding on a plan,
medical coverage, you
be sure to pick one with the
need to apply for dental
benefit options you prefer.
at the same time.
If you make changes to
your medical plan, you
must reselect your dental
plan or you will lose
your dental coverage.
Unless you qualify for
special enrollment, be
sure to enroll before
open enrollment ends,
Dec. 15, 2019.
8 92020 Dental plan benefit table
Delta Dental PPOSM Delta Dental EPO Delta Dental PPO Bright Smiles
Ages 0 – 18 Ages 19+ Ages 0 – 18 Ages 19+ Ages 0 – 18 Ages 19+
In-network, Out-of-network, In-network, Out-of-network, In-network, Out-of-network, In-network, Out-of-network, In-network, Out-of-network, In-network, Out-of-network,
you pay you pay you pay you pay you pay you pay you pay you pay you pay you pay you pay you pay
Calendar year costs
Deductible per person $0 $0 $0
$350 for one member / $700 for two or more members $350 for one member / $700 for two or more members $350 for one member / $700 for two or more members
Out-of-pocket max per person (ages 0 – 18)
(in-network only) (in-network only) (in-network only)
Annual benefit max (age 19+) $1,000 $1,500 N/A
Class 1
Exams and X-rays 0% 40% 25% 50% 0% Not covered 0% Not covered 0% 40% Not covered
Cleanings 0% 40% 25% 50% 0% Not covered 0% Not covered 0% 40% Not covered
Periodontal maintenance 0% 40% 25% 50% 0% Not covered 0% Not covered 0% 40% Not covered
Sealants 0% 40% 25% 50% 0% Not covered 0% Not covered 0% 40% Not covered
Topical fluoride 0% 40% 25%1 50%1 0% Not covered 0%1 Not covered 0% 40% Not covered
Class 2
Space maintainers 75% 75% Not covered Not covered 30% Not covered Not covered Not covered 75% 75% Not covered
Restorative fillings2 75% 75% 40% 50% 30% Not covered 30% Not covered 75% 75% Not covered
Class 3
Oral surgery3 75% 75% 50% 50% 50% Not covered 50% Not covered 75% 75% Not covered
Endodontics3 75% 75% 50% 50% 50% Not covered 50% Not covered 75% 75% Not covered
Periodontics 3
75% 75% 50% 50% 50% Not covered 50% Not covered 75% 75% Not covered
Restorative crowns 3
75% 75% 50% 50% 50% Not covered 50% Not covered 75% 75% Not covered
Bridges 3
Not covered Not covered 50% 50% Not covered Not covered 50% Not covered Not covered Not covered Not covered
Partial and complete dentures3 75% 75% 50% 50% 50% Not covered 50% Not covered 75% 75% Not covered
Anesthesia3 75% 75% 50% 50% 50% Not covered 50% Not covered 75% 75% Not covered
Orthodontia4 75% 75% Not covered Not covered 50% Not covered Not covered Not covered 75% 75% Not covered
Features
Delta Dental All other Delta Dental All other Delta Dental All other Delta Dental All other Delta Dental All other
Provider network N/A
PPO Network providers PPO Network providers PPO Network providers PPO Network providers PPO Network providers
Delta Dental Delta Dental Delta Dental
Delta Dental Premier Delta Premier Delta Dental Delta Dental Premier
Delta Dental PPO
Balance bill PPO Network: No Dental PPO Network: No PPO Network: Yes Yes PPO Network: Network: No N/A
Network: No
Network: No Nonparticipating: Network: No Nonparticipating: No No Nonparticipating:
Yes Yes Yes
1. Covered once in a 12-month period if there is recent history of periodontal surgery or high-risk of decay 3. 12-month exclusion period for ages 19 and over if member does not have 12 continuous months of prior dental coverage with no more
because of medical disease or chemotherapy or similar type of treatment. than a 90-day break in coverage from the end of the old policy to the effective date of the 2020 Delta Dental policy.
2. Six-month exclusion period for ages 19 and over if member does not have 12 continuous months of prior dental coverage with no more 4. Only medically necessary orthodontia to treat cleft palate is covered.
than a 90-day break in coverage from the end of the old policy to the effective date of the 2020 Delta Dental policy.
10 11Plan Rates
Calculate what you
pay each month
Our plans offer competitive premiums — the amount you pay each month
for coverage. If you want great benefits and value, you’re in good hands.
What affects your premium? Having a birthday during a plan year
The plan, your age and the ages of your won’t affect your current premium.
dependents may affect your premium When you renew your plan in January,
amount. If you have more than three your premium will reflect the current
dependents under age 21 on the plan, you plan amount for your age.
will only be charged a premium for the first Yearly premium updates
three. Child dependents ages 21 through 25 We adjust premiums for individual
have a premium based on their actual age. and family plans each year. You’ll
How your premium could change receive a renewal notice prior to the
new plan effective date explaining any
2020 premiums are effective Jan. 1, 2020, changes to your plan and premium.
through Dec. 31, 2020. Your premium
could change during the plan year if you Dental plan premiums
add a family member through a special These premiums apply to members
enrollment. If that happens, in most who live anywhere in Oregon.
cases the new premium is effective the
first of the month following the special
enrollment event. Your premium may also
change if you remove a family member.
2020 Delta Dental 2020 Delta Dental 2020 Delta Dental
Age
PPO Rate EPO Rate Bright Smiles Rate
0-18 $37 $40 $37
19-21 $26 $29
22-24 $26 $29
25-29 $26 $29
30-34 $28 $31
35-39 $31 $34
40-44 $32 $35
45-49 $33 $36
50-54 $36 $39
55-59 $40 $43
60-63 $43 $47
64+ $45 $49.50
12 Premiums effective Jan. 1, 2020 through Dec. 31, 2020 13FAQs
Answers to
your questions
What payment methods How will I make my Does it matter which dentist I see?
do you accept? first premium payment? Yes. You’ll save money by seeing an
in-network provider for your plan.
We accept electronic funds transfer You’ll receive your first premium invoice
(EFT) from a savings or checking prior to your effective date, either by mail
account, and ACH (automated clearing or by email. If you enrolled directly through Can I switch to a
house) payments, checks and money us, use the payment method you chose different plan at any time?
orders. Just select the billing and during enrollment to pay your premium.
payment option that is best for you: If you enrolled through the Marketplace, No. You will only be able to change medical
and/or dental plans during open enrollment.
• Paper bill. We’ll send you a paper bill HealthCare.gov, make your payment using
If you experience a qualifying event, such as
in the mail every month. You can mail one of the methods listed in your welcome
letter. Once your first invoice is ready, you getting married or moving to a new state, you
back your payment in the enclosed
can log in to your Member Dashboard may be able to apply for special enrollment
envelope or make a payment through
to manage your payment method and outside of the open enrollment period.
electronic funds transfer or eBill.
• Electronic funds transfer (EFT). There set up recurring payments with eBill.
Which plans can I purchase
are three ways to sign up for EFT. You Future invoices will arrive around the
may complete the online application tenth of each month and payments are through the federal Marketplace?
form, the paper application, or contact due by the first of the following month. You can enroll in all Moda Health individual
us and we can help you complete
medical plans through ShopModaPlans.com
the authorization form. EFT takes Can my employer pay and HealthCare.gov. To enroll in a Delta Dental
place around the fifth of the month
and typically takes one or two days for my individual coverage? plan through HealthCare.gov, you must
to post to your account. Your initial enroll in a medical plan at the same time.
Individual plans cannot be employer- If you make changes to your medical
payment may occur on a later date if sponsored plans but small employers may
the enrollment is processed after the plan, you must reselect your dental plan
offer a Qualified Small Employer Health or you will lose your dental coverage.
fifth of the month. Your premium invoice Reimbursement Arrangement (QSEHRA) and
will be paperless, located in the eBill
pay for individual plan premiums. Check with
section of your Member Dashboard.
your employer if this option is available and
• eBill, our electronic billing service. how reimbursement is made. Otherwise, you
You can review your premium invoice will be responsible for paying your monthly
and make payments online through premiums directly to Delta Dental of Oregon.
the Member Dashboard, your
personalized member website.
You will be sent a paper bill and can
go online to select paperless billing.
You can set up recurring payments or
initiate a payment each month. Visit
DeltaDentalOR.com to log in
to our Member Dashboard
account. If you don’t have an
account, you can create one.
14Glossary Limitations and exclusions for dental plans
Healthcare
These are some common limitations and exclusions for our 2020 Delta Dental of Oregon individual
and family dental plans. For a full list of limitations and exclusions per plan or for copies of
plan summaries, please see back cover for our sales and service team contact information.
lingo explained Limitations
Class 1
-- Bitewing X-rays once in a 12-month period -- Periodontal surgical procedures by the same
-- Exam once in a six-month period dentist at the same site are covered once in
We realize that health plans can be confusing, so we’ve made -- Fluoride once in a six-month period --
a 3 year period for members 19 and over.
Porcelain crowns on back teeth are limited
under age 19 and once every 12 months
you a cheat sheet of sorts. To find even more definitions, if there is recent history of periodontal to the amount for a full metal crown.
visit the Learning Center at ShopModaPlans.com. surgery or high risk of decay due to -- Scaling and root planing is limited to
medical disease or chemotherapy or once per quadrant in any 2-year period
similar type of treatment for age 19+
-- Full-mouth or panoramic X-rays Exclusions
Balance billing Maximum plan allowance (MPA) once in a five-year period -- Anesthetics, analgesics, hypnosis
-- Interim caries arresting medicament and most medications, including
Charges for out-of-network care beyond MPA is the maximum amount that we will application is covered twice per tooth nitrous oxide for adults
what your dental plan allows. Out-of-network reimburse providers. A non-contracted per year. Many restorations are not -- Charges above the maximum plan allowance
providers may bill members the difference provider may bill a member for any amount covered within 3 months of interim caries
arresting medicament application.
-- Charting (including periodontal, gnathologic)
between the maximum plan allowance and
their billed charges. In-network providers
over and above the MPA. This may leave
members with a high out-of-pocket balance. -- Prophylaxis (cleaning) or periodontal
-- Congenital or developmental malformations
don’t do this for covered services. maintenance is covered once in -- Cosmetic services
Out-of-pocket costs any six-month period. Additional -- Duplication and interpretation
periodontal maintenance is covered of X-rays or records
Coinsurance What members pay in a calendar year for members with periodontal -- Experimental or investigational treatment
The percentage members pay for a for care after their dental plan pays its disease, up to a total of 2 additional -- Hospital costs or other fees for facility
covered dental service after they meet their portion. These expenses may include periodontal maintenances per year. or home care except for emergency
deductible, if any. For example, they may pay deductibles, coinsurance for covered -- Sealants limited to unrestored occlusal care for members under age 19
30 percent of an allowed expenses and cost of care after the dental surface of permanent molars once -- Implants
$200 charge, or $60. annual maximum has been exhausted. per tooth in a five-year period except
for evidence of clinical failure
-- Instructions or training (including
plaque control and oral hygiene
or dietary instruction)
Deductible Out-of-pocket maximum Class 2 and Class 3
-- Athletic mouth guard covered once -- Orthodontia (exception for treatment
The amount members pay in a calendar year The most members (ages 0-18 only) pay of cleft palate under age 19)
for care that requires a deductible before in a calendar year for pediatric dental care in any 12-month period for members
age 15 and under and once in any -- Over-the-counter night guards
the dental plan starts paying. Disallowed services before benefits are paid in full, up and athletic mouth guards
24-month period age 16 and over
charges do not apply toward the deductible. to the allowable amount or up to any visit
-- Bridges once in a seven-year -- Rebuilding or maintaining chewing
limit. Once members meet the out-of-pocket period age 19 and over
surfaces (misalignment or
Dental annual maximum maximum, the plan covers eligible expenses
-- malocclusion) or stabilizing teeth
at 100 percent. The out-of-pocket maximum
Crowns and other cast restorations
once in a seven-year period -- Self treatment
The maximum dollar amount a
dental plan will pay toward the cost
includes deductible and coinsurance. It does
-- Crown over implant once -- Services or supplies available under any city,
not include disallowed charges or balance per lifetime per tooth.
county, state or federal law, except Medicaid
of dental care for members ages 19
and over within a calendar year.
billing from out-of-network dentists.
-- Dentures once in a seven-year -- Teledentistry, translation or sign language
services are not covered as separate charges
period age 16 and over
PPO dentist -- IV sedation or general anesthesia only -- Temporomandibular joint syndrome (TMJ)
Marketplace with surgical procedures. Oral anesthesia -- Treatment before coverage begins
A dentist contracted in the Delta or after coverage ends
Also called an Exchange, a health plan only for members under age 19 used
Marketplace is where people can buy
Dental PPO network. By enrolling in a
PPO plan and choosing a PPO dentist,
during an in-office procedure. -- Treatment not dentally necessary
health coverage and apply for federal members’ out-of-pocket expenses will -- Night guard (occlusal guard) covered at
financial assistance. Oregon residents use 100 percent once in a five year period, up to
be less than if they choose a dentist $150 maximum. Repair and reline of occlusal
the federal Marketplace, HealthCare.gov. outside of the PPO network. guard are covered once every 12-month
period. One occlusal guard adjustment
is covered every 12-month period.
16 17Nondiscrimination notice
We follow federal civil rights laws. ATENCIÓN: Si habla español, અગત્યનું: જો તમે (ભાષાંતર કરેલ ભાષા અહી ં
We do not discriminate based hay disponibles servicios de દર્શાવો) બોલો છો તો તે ભાષામાં તમારે માટે
on race, color, national origin, ayuda con el idioma sin costo વિના મૂલ્યે સહાય ઉપલબ્ધ છે. 1-877-605-
alguno para usted. Llame al 3229 (TTY: 711) પર કૉલ કરો
age, disability, gender identity, 1-877-605-3229 (TTY: 711).
sex or sexual orientation. ໂປດຊາບ: ຖ້ າທ່ ານເວົ້ າພາສາລາວ, ກາ
CHÚ Ý: Nếu bạn nói tiếng ນຊ່ ວຍເຫື ຼ ອດ້ ານພາສາແມ່ ນມີ ໃຫ້ ທ່ ານໂ
We provide free services to people Việt, có dịch vụ hổ trợ ngôn ດຍບໍ່ ເສັ ຍຄ່ າ.
with disabilities so that they can ngữ miễn phí cho bạn. Gọi ໂທ 1-877-605-3229 (TTY: 711)
communicate with us. These include 1-877-605-3229 (TTY:711)
sign language interpreters and УВАГА! Якщо ви говорите
other forms of communication. 注意：如果您說中文，可得到免 українською, для вас доступні
費語言幫助服務。請致電1-877- безкоштовні консультації
If your first language is not English, we 605-3229（聾啞人專用：711） рідною мовою. Зателефонуйте
will give you free interpretation services 1-877-605-3229 (TTY: 711)
주의: 한국어로 무료 언어 지원
and/or materials in other languages. 서비스를 이용하시려면 다음 ATENȚIE: Dacă vorbiți limba
연락처로 연락해주시기 바랍니다. română, vă punem la dispoziție
If you need any of the above, 전화 1-877-605-3229 (TTY: 711) serviciul de asistență lingvistică
call Customer Service at: în mod gratuit. Sunați la
PAUNAWA: Kung nagsasalita 1-877-605-3229 (TTY 711)
888-217-2363 (TDD/TTY 711) ka ng Tagalog, ang mga
serbisyong tulong sa wika, ay THOV CEEB TOOM: Yog hais
If you think we did not offer these services walang bayad, at magagamit tias koj hais lus Hmoob, muaj
or discriminated, you can file a written mo. Tumawag sa numerong cov kev pab cuam txhais lus,
complaint. Please mail or fax it to: 1-877-605-3229 (TTY: 711) pub dawb rau koj. Hu rau
1-877-605-3229 (TTY: 711)
Moda Partners, Inc. فهناك خدمات، إذا كنت تتحدث العربية:تنبيه
Attention: Appeal Unit اتصل برقم.مساعدة لغوية متاحة لك مجانًا ត្រូវចងចាំ៖ ប�ើអ្នកនិយាយភាសាខ្មែរ
601 SW Second Ave. )711 : (الهاتف النصي1-877-605-3229 ហ�ើយត្រូវការសេវាកម្មជំនួ
Portland, OR 97204 យផ្នែកភាសាដោយឥតគិតថ្
Fax: 503-412-4003 ( وتہج ن ی تURDU)
ارگ آپ اردو:�د
ہ
លៃ គឺមានផ្ដល់ជូនលោកអ្នក។
لآپ ےک ی وبےتل ي� وت اسلین ااع� ت សូមទូរស័ព្ទទៅកាន់លេខ
If you need help filing a complaint, دساب ےہ۔ الب اعموہض ی1-877- 1-877-605-3229 (TTY: 711)
please call Customer Service. 605-3229 (TTY: 711)�رک رپ اکل ی
HUBACHIISA: Yoo afaan Kshtik kan
You can also file a civil rights complaint ВНИМАНИЕ! Если Вы говорите dubbattan ta’e tajaajiloonni
with the U.S. Department of Health and по-русски, воспользуйтесь gargaarsaa isiniif jira
Human Services Office for Civil Rights at бесплатной языковой 1-877-605-3229 (TTY:711)
ocrportal.hhs.gov/ocr/portal/lobby.jsf, поддержкой. Позвоните по тел. tiin bilbilaa.
or by mail or phone: 1-877-605-3229 (текстовый
телефон: 711). โปรดทราบ: หากคุณพูดภาษาไทย คุณ
U.S. Department of Health สามารถใช้บริการช่วยเหลือด้านภาษาได้ฟรี
and Human Services ATTENTION : si vous êtes โทร 1-877-605-3229 (TTY: 711)
200 Independence Ave. SW, Room 509F locuteurs francophones, le
HHH Building, Washington, DC 20201 service d’assistance linguistique FA’AUTAGIA: Afai e te tautala i
gratuit est disponible. Appelez le gagana Samoa, o loo avanoa
800-368-1019, 800-537-7697 (TDD) au 1-877-605-3229 (TTY : 711) fesoasoani tau gagana mo
You can get Office for Civil Rights complaint oe e le totogia. Vala’au i le
forms at hhs.gov/ocr/office/file/index.html. در صورتی که به فارسی صحبت:توجه 1-877-605-3229 (TTY: 711)
خدمات ترجمه به صورت رایگان،می کنید
1-877-605- با.برای شما موجود است IPANGAG: Nu agsasaoka iti
Dave Nesseler-Cass coordinates .) تماس بگیریدTTY: 711( 3229 Ilocano, sidadaan ti tulong iti
our nondiscrimination work: lengguahe para kenka nga
Dave Nesseler-Cass, ध्यान दें : यदि आप हिंदी बोलते हैं, तो आपको awan bayadna. Umawag iti
Chief Compliance Officer भाषाई सहायता बिना कोई पैसा दिए उपलब्ध है। 1-877-605-3229 (TTY: 711)
1-877-605-3229 पर कॉल करें (TTY: 711)
601 SW Second Ave.
UWAGA: Dla osób mówiących po
Portland, OR 97204 Achtung: Falls Sie Deutsch polsku dostępna jest bezpłatna
855-232-9111 sprechen, stehen Ihnen kostenlos pomoc językowa. Zadzwoń:
compliance@modahealth.com Sprachassistenzdienste zur 1-877-605-3229
Verfügung. Rufen sie 1-877- (obsługa TTY: 711)
605-3229 (TTY: 711)
注意：日本語をご希望の方には、日
本語サービスを無料で提供してお
ります。1-877-605-3229（TYY、
テレタイプライターをご利用の
方は711）までお電話ください。
18Individual & family
Small group
Large group
Questions? We’re here to help.
Contact a Delta Dental-appointed agent,
or call us toll-free at 855-718-1767.
TTY users, please call 711.
DeltaDentalOR.com
Dental plans in Oregon provided by Oregon Dental Service, dba Delta Dental Plan of Oregon.
59245846 (9/19)You can also read
