Delta Dental

Delta Dental PPO plus Premier

Schedule of Benefits for ARKANSAS ASSOCIATION OF CORRECTIONAL EMPLOYEES

 Effective Date: 09/01/2013 12:01 a.m. Central Standard Time

Group Number: 3879

Deductible: Applies to Basic Restorative Services and Major Restorative Services per benefit period.

 

Premier and PPO In Network

Out-of-Network

 

Individual

$25 

$25

 

Annual and Lifetime Maximum Payment:  The annual maximum amount applies to Diagnostic and Preventative Services, Basic Restorative Services and Major Restorative Services per benefit period.

 

Premier and PPO In Network 

Out-of-Network

 

Annual  Individual

$1,500

$1,500

 

Lifetime Orthodontic

$1,000  

$1,000

Benefit period: A benefit period for each eligible participant shall mean a calendar year, the period from January 1st to December 31st of each year.

Dependent Age Limit: To the end of the month year in which the child reaches age 26.

Coverages and Maximum Plan Allowances (MPA)

Coverage A – Diagnostic and Preventative Services

Premier In Network 100% MPA

 

PPO In Network 100% MPA

 

Out-Of-Network 90% MPA

 

  • Routine periodic and specialty evaluations are Covered Services up to two (2) time(s) in any Calendar Year. This is inclusive of an initial, oral evaluation.

  • Prophylaxis (Cleaning) is a Covered Service up to two (2) time(s) per Calendar Year.(*Please see information on Evidence Based Dentistry.)

  • Sealants are Covered Services for Eligible Dependents prior to age sixteen (16) one (1) time(s) per tooth per lifetime.

  • Topical application of fluoride is a Covered Service one (1) time(s) per Calendar Year for Eligible Dependents prior to age nineteen (19).

  • Bitewing and periapical x-rays are Covered Services as required in any Calendar Year.

  • A full mouth series x-ray or panoramic x-ray is a Covered Service one (1) time(s) within any sixty (60) consecutive month period.

 

Coverage B – Basic Restorative Services

Premier In Network 80% MPA

 

PPO In Network 80% MPA

 

Out-Of-Network 72% MPA

 

  • Palliative treatment is a Covered Service once per visit as long as no other procedures, except for x-rays, exams, or any diagnostic service, are performed on the same date.

  • Restorative benefits (fillings) are Covered Services once per surface, per tooth in a twenty-four (24) month period.

  • Non-surgical periodontics.

  • Periodontal Maintenance is a Covered Service up to two (2) per Calendar Year following active periodontal treatment. (*Please see information on Evidence Based Dentistry below.)

  • Stainless Steel Crowns used as a restoration to natural teeth are Covered Services for Eligible Dependent(s) to age sixteen (16) when the teeth cannot be restored with a filling material.

  • Simple extractions.

  • A space maintainer is a Covered Service when used to replace prematurely lost or extracted teeth for Eligible Dependents prior to age fourteen (14).

  • A space maintainer is a Covered Service up to one (1) time(s) in a sixty (60) consecutive month period.

     

Coverage C – Major Restorative Services

Premier In Network 50% MPA

 

PPO In Network 50% MPA

 

Out-Of-Network 45% MPA

 

  • Brush Biopsy is a Covered Service upon consultant review.

  • Oral surgery, except TMJ surgery, is a Covered Service.

  • Root canal treatment is a Covered Service once in a lifetime, per tooth, by the same Provider or Provider’s office that performed the root canal. Benefits for root canal treatment include charges for temporary restorations.

  • Surgical periodontics.

  • Crowns, inlays, onlays, and veneers are Covered Services for the treatment of visible decay and fractures of tooth structure when teeth are so badly damaged they cannot be restored with amalgam or composite restorations.

  • Replacement of a crown, inlay, onlay, or veneer is a Covered Service only after sixty (60) months of the previous prosthetic.

  • Endosteal implants are Covered Services once in a lifetime per tooth.

  • Prosthodontics, including procedures for construction of fixed bridges, partial or complete dentures, and repair of fixed bridges.

  • Replacement of partial removable or complete dentures that the Participant received in the previous sixty (60) consecutive months are not Covered Services except where the loss of additional teeth requires the construction of a new appliance.

     

Child Orthodontic Services

Premier In Network 50% MPA

 

 

PPO In Network 50% MPA

 

 

Out-Of-Network 45% MPA

 

 

Orthodontic services for children to age 19

The initial payment made by DDAR for comprehensive treatment cannot be more than one-third (1/3) of the total fee for treatment.  Subsequent payment(s) will be issued on a regular basis for continuing, active orthodontic treatment. Payment(s) will begin the month after the beginning of treatment.  Payments are subject to the participants’ co-payment percentage and lifetime maximum.  Orthodontia is considered a pre-existing condition if treatment begins prior to the date he/she became eligible under this plan.

Carry-over Benefit

Carry-over benefit: $375

Claims threshold: $749

Carry-over benefit maximum: $1,500

* Evidence Based Dentistry:  DDAR covers additional routine cleanings or periodontal maintenance procedures up to four per benefit period year for Participants with diabetes, heart disease, who are pregnant or have a history of periodontal disease. The additional benefits may not be combined by those with more than one of the above conditions.

Questions? Contact Delta Dental’s Customer Service Department at (800) 462-5410.

Delta Dental’s network of participating providers may be found on our website at www.deltadentalar.com

 

Affordable biweekly rates that are added to your AACET dues:

  • Employee only - $9.35
  • Employee + spouse - $20.53
  • Employee + child(ren) - $21.81
  • Employee + family - $30.30

 

See your Human Resources Manager or Benefits Specialist for AACET application and dental enrollment form or download from the Forms link. 


THIS INSURANCE IS NOT BEING OFFERED THROUGH THE STATE OF ARKANSAS.  DELTA VISION INSURANCE IS BEING OFFERED EXCLUSIVELY THROUGH AACET FOR AACET MEMBERS ONLY.