Delta Dental of Oklahoma - Select

Last Printed: May 2016

Checklist for New Groups    

Application Checklist for New Groups    When enrolling in a new group, there are several key areas essential in providing a smooth implementation to  Delta Dental. In order to better serve our brokers and clients, we have developed a checklist to aid in the  process of enrolling and setting up new groups with Delta Dental.       Application for Group Contract completed in its entirety and signed by the person authorized to    contract for the group.      Individual enrollment form completed and signed by each employee enrolling in the dental plan;    enrollment may also be submitted by electronic file. For more information on acceptable electronic file    formats, please contact [email protected].       If electing Federally Compliant Plan/Plans:      Federally Compliant Plan Application for Group Contract completed in its entirety and signed by the    person authorized to contract for the group.      Federally Compliant Plan Individual enrollment form completed and signed by each employee enrolling    in the Federally Compliant dental plan; enrollment may also be submitted by electronic file. For more    information on acceptable electronic file formats, please contact [email protected].      The placement of your group with Delta Dental of Oklahoma is important to us and very much appreciated. If  you have any questions, please feel free to call us at 405‐607‐4709 (OKC Metro) or 866‐685‐2112 (Toll Free) or  email us at [email protected].     Please mail new group submissions to:  Delta Dental of Oklahoma  Attention: Sales  P.O. Box 54709  Oklahoma City, Oklahoma 73154‐1709    or send an email to:    [email protected]  

Delta Dental of Oklahoma ‐ Select  

Number of Eligible Employees: 2‐99†  Proposed Effective Date: January – December 2016 (1st day of selected month)   

Delta Dental of Oklahoma – Select for employer groups is a unique approach to providing solutions to the ever changing needs of employees.  With Delta Dental – Select, employers can provide their employees the opportunity to select from the menu of plans listed below.   

Plan Options: 

Delta Dental  Patient Direct  Discount  Program 

Delta Dental  PPO 

Federally Compliant  Plans for Covered  Person(s) to age 19  Only** 

Delta Dental  PPO – Plus  Premier  “Elite” 

Delta Dental  PPO – Plus  Premier 

High           Low 

Preventive/Diagnostic Services 

Discount 

 

100% 

 

100% 

 

100% 

 

 100% 

   100% * 

Basic Services 

Discount 

 

  80% *    

 

  80% * 

 

  80% * 

 

   80% * 

     60% * 

Major Services 

Discount 

 

  50% * 

 

  50% * 

 

  50% * 

 

   50% * 

     50% * 

Orthodontic Services 

Discount 

 

  50%  Child Only 

 

  50%  Child Only 

 

  50%  Family 

Per Person Deductible 

N/A 

$50 

$50 

$50 

$25 

$100 

Annual Maximum 

N/A 

$1,500  Per Person 

$1,500  Per Person 

$3,000  Per Person 

N/A 

N/A 

Orthodontic Lifetime Maximum 

N/A 

$1,500  Per Child 

$1,500  Per Child 

$2,000  Per Person 

N/A 

N/A 

Maximum Out‐of‐Pocket –  1 covered person 

N/A 

N/A 

N/A 

N/A 

$350 

$350 

Maximum Out‐of‐Pocket –  2 or more covered persons 

N/A 

N/A 

N/A 

N/A 

$700 

$700 

Additional Benefits Available 

N/A 

N/A 

N/A 

See Program  of Benefits 

N/A 

N/A 

 

   50%       50%  Medically  Medically  Necessary  Necessary 

 

† 

A minimum of two subscribers must be enrolled in either Delta Dental PPO, PPO – Plus Premier and/or PPO – Plus Premier “Elite” plans.   *   Per Person Deductible Applies  **   Benefits are based on the State Children’s Health Insurance Program (SCHIP) guidelines. Special processing policies/limitations/exclusions will    apply for medically necessary procedures. Deductibles and Co‐Insurance will apply to your Maximum Out‐of‐Pocket costs.     This is not an insured program.         Medically Necessary – Orthodontic treatment and/or services are only covered with orthognathic surgery cases or certain designated            syndromes or genetic disorders such as cleft palate. Benefits are only allowed for medically necessary orthodontic services to help correct             severe handicapped malocclusions caused by cranio‐facial orthopedic deformities involving teeth. 

 

Monthly Rates:  Employee Only  Employee + Spouse  Employee + Child(ren)  Family  One Child  Two Children  Three or more children   

Patient Direct  $5.00  N/A  N/A  $7.00  N/A  N/A  N/A 

PPO  $  32.00  $  64.00  $  80.00  $107.00  N/A  N/A  N/A 

PPO – Plus  Premier  $  36.00  $  72.00  $  98.00  $144.00  N/A  N/A  N/A 

PPO – Plus  Premier “Elite”  $  63.00  $128.00  $166.00  $237.00  N/A  N/A  N/A 

Federally Compliant  High            Low  N/A  N/A  N/A  N/A  N/A  N/A  N/A  N/A  $30.51  $18.80  $61.02  $37.60  $91.53  $56.40 

Delta Dental of Oklahoma ‐ Select   Program of Benefits: Delta Dental PPO 

  Delta Dental of Oklahoma’s benefits consist of Diagnostic and Preventive Services, Basic Services, Major Services and Orthodontic  Services. The benefits listed below are not a complete list. Limitations to benefits can be found in the Summary Plan Description.     Diagnostic and Preventive Services (Class I Benefits)   Oral evaluation   Routine prophylaxis, including cleaning and polishing   Bitewing and periapical x‐rays   Full‐mouth x‐rays   Space maintainers for eligible dependent children only   Minor emergency (palliative) treatment for relief of pain   Topical application of fluoride for eligible dependent children only   Topical application of sealants for eligible dependent children only, limited to permanent first and second molars free of  caries and restorations on the occlusal surface   Periodontal maintenance    Note:  Benefits paid by the Plan for covered oral evaluations and routine prophylaxis will not reduce your Benefit Year    Maximum Payment for combined Class I, Class II and Class III covered dental services.    Basic Services (Class II Benefits)   Amalgam and composite fillings   Stainless steel crowns for eligible dependent children only when the natural teeth cannot be restored with another  filling material   General Anesthesia/IV Sedation – when administered by a properly licensed dentist, in the dental office, in conjunction  with covered oral surgery or when necessary due to concurrent medical conditions   Endodontics – includes pulpal therapy and root canal treatment   Oral Surgery – extractions and other covered oral surgery procedures   Periodontics – procedures performed for the treatment of diseases of the gums and supporting structures of the teeth,  excluding periodontal maintenance procedures which is payable as a Diagnostic/Preventive Service (Class I)    Major Services (Class III Benefits)   Major Restorative – provides porcelain or cast restorations (other than stainless steel) when teeth cannot be restored with  another filling material   Prosthodontics – procedures for construction of fixed bridges, partial dentures and complete dentures   Implants – procedures for implant placement, maintenance and repair of implants, and implant‐supported prosthetics    Orthodontics (Class IV Benefits)   The necessary treatment and  procedures required  for the correction  of malposed teeth    Orthodontic coverage  is a benefit provided for dependent children only to the age of 26. 

Delta Dental of Oklahoma ‐ Select   Program of Benefits: Delta Dental PPO – Plus Premier 

  Delta Dental of Oklahoma’s benefits consist of Diagnostic and Preventive Services, Basic Services, Major Services and Orthodontic  Services. The benefits listed below are not a complete list. Limitations to benefits can be found in the Summary Plan Description.     Diagnostic and Preventive Services (Class I Benefits)   Oral evaluation   Routine prophylaxis, including cleaning and polishing   Bitewing and periapical x‐rays   Full‐mouth x‐rays   Space maintainers for eligible dependent children only   Minor emergency (palliative) treatment for relief of pain   Topical application of fluoride for eligible dependent children only   Topical application of sealants for eligible dependent children only, limited to permanent first and second molars free of  caries and restorations on the occlusal surface   Periodontal maintenance    Note:  Benefits paid by the Plan for covered oral evaluations and routine prophylaxis will not reduce your Benefit Year    Maximum Payment for combined Class I, Class II and Class III covered dental services.    Basic Services (Class II Benefits)   Amalgam and composite fillings   Stainless steel crowns for eligible dependent children only when the natural teeth cannot be restored with another  filling material   General Anesthesia/IV Sedation – when administered by a properly licensed dentist, in the dental office, in conjunction  with covered oral surgery or when necessary due to concurrent medical conditions   Endodontics – includes pulpal therapy and root canal treatment   Oral Surgery – extractions and other covered oral surgery procedures   Periodontics – procedures performed for the treatment of diseases of the gums and supporting structures of the teeth,  excluding periodontal maintenance procedures which is payable as a Diagnostic/Preventive Service (Class I)    Major Services (Class III Benefits)   Major Restorative – provides porcelain or cast restorations (other than stainless steel) when teeth cannot be restored with  another filling material   Prosthodontics – procedures for construction of fixed bridges, partial dentures and complete dentures   Implants – procedures for implant placement, maintenance and repair of implants, and implant‐supported prosthetics    Orthodontics (Class IV Benefits)   The necessary treatment and  procedures required  for the correction  of malposed teeth    Orthodontic coverage is a benefit provided for dependent children only to the age of 26. 

 

Delta Dental of Oklahoma ‐ Select   Program of Benefits: Delta Dental PPO – Plus Premier “Elite”   

Delta Dental of Oklahoma’s benefits consist of Diagnostic and Preventive Services, Basic Services, Major Services and Orthodontic  Services. The benefits listed below are not a complete list. Limitations to benefits can be found in the Summary Plan Description.    

Diagnostic and Preventive Services (Class I Benefits)   Oral evaluation   Routine prophylaxis, including cleaning and polishing and/or Periodontal maintenance (maximum combined total  of four)   Bitewing and periapical x‐rays   Full‐mouth x‐rays   Space Maintainers for eligible dependent children only   Minor emergency (palliative) treatment for relief of pain   Topical application of fluoride for eligible dependent children only   Topical application of sealants for eligible dependent children only, limited to permanent first and second molars free of  caries and restorations on the occlusal surface   

Note:  Benefits paid by the Plan for covered oral evaluations and routine prophylaxis will not reduce your Benefit Year    Maximum Payment for combined Class I, Class II and Class III covered dental services.    

Basic Services (Class II Benefits)   Amalgam and composite fillings   Stainless steel crowns for eligible dependent children only when the natural teeth cannot be restored with another  filling material   General Anesthesia/IV Sedation – when administered by a properly licensed dentist, in the dental office, in conjunction with  covered oral surgery or when necessary due to concurrent medical conditions   Endodontics – includes pulpal therapy and root canal treatment   Oral Surgery – extractions and other covered oral surgery procedures   Periodontics – procedures performed for the treatment of diseases of the gums and supporting structures of the teeth,  excluding periodontal maintenance procedures which is payable as a Diagnostic/Preventive Service (Class I)   Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth   Non‐intravenous conscious sedation   Inhalation of nitrous oxide/analgesia, anxiolysis   

Major Services (Class III Benefits)   Major Restorative – provides porcelain or cast restorations (other than stainless steel) when teeth cannot be restored with  another filling material   Prosthodontics – procedures for construction of fixed bridges, partial dentures and complete dentures   Implants – procedures for implant placement, maintenance and repair of implants, and implant‐supported prosthetics   Other drugs and/or medicaments, by report   Application of desensitizing medicament   Occlusal guard   Repair or reline of the occlusal guard   External bleaching tray – per arch – performed in office    Orthodontics (Class IV Benefits)   The necessary treatment and procedures required for the correction of malposed teeth    Orthodontic coverage is a benefit provided for the entire family. 

  

Delta Dental of Oklahoma ‐ Select

For Delta Dental of Oklahoma Use Only: Group No.___________________ For group sizes with 2-99 Eligible

APPLICATION FOR GROUP CONTRACT (Delta Dental Select) This Application For Group Contract is hereby made a part of the Plan Agreement, and is subject to all terms and conditions of the Agreement thereof. This Application For Group Contract will not be accepted by Delta Dental unless completed in its entirety.

PLAN EFFECTIVE DATE

ERISA EXEMPT:

GROUP NAME

GROUP EXECUTIVE

Yes

No

Title STREET ADDRESS

Phone No./Fax. No. E-Mail Address

MAILING ADDRESS

GROUP CONTACT Phone No./Fax No.

TELEPHONE NO. FACSIMILE NO.

( ) (

E-Mail Address

)

BILLING CONTACT

WEBSITE ADDRESS

Phone No./Fax No.

FEDERAL TAX ID NO.

E-Mail Address

TYPE OF BUSINESS

ELIG. CONTACT

SIC CODE

Phone No./Fax No. E-Mail Address

ELIGIBILITY/ENROLLMENT: Total Employees:

Minus Ineligible = Total Eligible Employees Explain Ineligible Employees, e.g., part-time, etc.: Note: Participation requirement of a minimum of two (2) enrolled Eligible Employees.

Waiting Periods: New Employees: A new employee’s coverage will become effective the first of the month following sixty (60) days of continuous full-time employment. Employer Monthly Contribution to the Employee Cost of Plan:

% or $

Billing Notification: E-Bill (e-mail notice) Facsimile US Mail Payment Options: Pay-by-Phone Automatic Draft FastPay™ On-Line Check Payment FULLY INSURED PLAN OPTIONS: Please check the box of the option(s) you are making available to your employees MONTHLY RATES: Employee Only Employee + Spouse Employee + Children Employee + Family

Delta Dental PPO $32.00 $64.00 $80.00 $107.00

Delta Dental PPO Plus Premier $36.00 $72.00 $98.00 $144.00

Delta Dental PPO Plus Premier – “Elite” $63.00 $128.00 $166.00 $237.00

(Please complete the reverse side of this Application)

Form No. DDOK Select APP.2 July 2014

CONFIDENTIAL

BENEFITS SUMMARY - Delta Dental PPO Covered Services & Plan Co-payment Percentages:

Class I - Diagnostic & Preventive Services ......................................... 100% Class II - Basic Services.......................................................................... 80% Class III - Major Restorative Services...................................................... 50% Class IV - Orthodontic Services………………....................................... 50% Maximum Benefit Payment Per Person Per Calendar Year - Classes I, II, and III Services combined .........................................$1,500 Maximum Lifetime Benefit Payment Per Eligible Dependent Child - Class IV Services .............................................................$1,500 Deductible Per Calendar Year (Classes II and III only)................................................................................................... $50 Per Person BENEFITS SUMMARY - Delta Dental PPO – Plus Premier Covered Services & Plan Co-payment Percentages: Class I - Diagnostic & Preventive Services ......................................... 100% Class II - Basic Services.......................................................................... 80% Class III - Major Restorative Services...................................................... 50% Class IV - Orthodontic Services………………....................................... 50% Maximum Benefit Payment Per Person Per Calendar Year - Classes I, II, and III Services combined .........................................$1,500 Maximum Lifetime Benefit Payment Per Eligible Dependent Child - Class IV Services .............................................................$1,500 Deductible Per Calendar Year (Classes II and III only)................................................................................................... $50 Per Person BENEFITS SUMMARY - Delta Dental PPO - Plus Premier – “Elite” Covered Services & Plan Co-payment Percentages: Class I - Diagnostic & Preventive Services ......................................... 100% Class II - Basic Services.......................................................................... 80% Class III - Major Restorative Services...................................................... 50% Class IV - Orthodontic Services………………....................................... 50% Maximum Benefit Payment Per Person Per Calendar Year - Classes I, II, and III Services combined .........................................$3,000 Maximum Lifetime Benefit Payment Per Person - Class IV Services...........................................................................................$2,000 Deductible Per Calendar Year (Classes II and III only)................................................................................................... $50 Per Person PRODUCER/CONSULTANT INFORMATION: Please complete the information requested below. Producer/Consultant Agency Street Address

Social Security No. Federal Tax ID No. Mailing Address

Business Phone No.( ) E-Mail Address

Fax No. ( ) Website Address HOLD HARMLESS

Delta Dental has not reviewed the employer’s request for plan coverage nor designed the group plan to meet any federal requirements for Discriminatory Employee Benefit Plans. Said plan may not be in compliance with criteria established for Discriminatory Employee Benefit Plans, and employer holds Delta Dental Plan of Oklahoma harmless if said plan fails to meet any such requirements. All information above is true and correct to the best of my knowledge.

I have reviewed the benefits and eligibility requirements as stated in this Group Application and accept them.

Producer/Consultant’s Signature

Employer’s Authorized Signature

Date

Title

Date Please mark if the following is submitted with this signed application:

Please ship my new group packet (plan agreement, etc.) to:

Enrollment forms Electronic enrollment data Check for first month’s premium

Producer/Consultant

Group Contact

Note: A set of identification cards and a dental Summary Plan Description will be mailed direct to the employee’s home, as indicated in the enrollment form or electronic enrollment data. Form No. DDOK Select APP.2 July 2014

CONFIDENTIAL

Automatic Draft Authorization

Purpose of Authorization (select one)  New authorization  Changes to existing authorization (Note: Changes will be completed within 30 days from date of receipt) Please print or type when completing this form. Name of Company: Group Number: Address: Phone Number:

Fax Number:

Name of Depositor: (Print name exactly as it appears on Financial Institution records)

Name of Financial Institution:

Branch:

Address: Phone Number: Type of Account:

 Checking

Savings

I (We) hereby authorize Delta Dental of Oklahoma and the financial institution named above to begin deductions of company dental premium from the account I have indicated herein. I understand that company eligibility can be placed on hold for a rejected draft. I also understand that this specified account would be deducted on the 5 th day of each month.* Print Name: Signature: **

Date:

Note: A voided check must be attached to this authorization to process intended application. Fax this form with a voided check to:

405-241-0680 -OR-

Mail this form with a voided check to:

Delta Dental of Oklahoma Attn: Finance P.O. Box 54709 Oklahoma City, Oklahoma 73154-1709

* If the 5th of the month falls on a weekend or holiday, Delta Dental of Oklahoma will debit the specified account on the next business day. ** Signature must be that of an authorized signer on the bank account. Group Auto. Draft form, Revised: October 2015

Application for Online Resources

Group Name: Group Number: Please complete the following to provide and/or change access in Online Resources. Subgroup Access: Named contact/contacts will receive access to the specified subgroup/subgroups. Online Eligibility: Named contact/contacts will receive access to view and/or modify eligibility in Online Resources. View Only: Read-only access to online eligibility. Modify: Ability to make changes through online eligibility. Billing: Named contact/contacts will receive access to billing. E-Bill: Access to receive the invoice through email. Bill by Fax: Access to receive the invoice by Fax. An email address is required for each contact requesting access to Online Resources. Enter the information for each contact that is to receive online access through Online Resources. If a contact should have access to all subgroups then enter “ALL” in the box. Select each type of access. You may choose one method of invoice receipt (E-Bill or Fax). An email address is required. Add the fax number if selecting Bill by Fax.

Contact Name

Online Resources User Name if previously assigned

Subgroup(s) Access

Select One Online Eligibility View Only

Modify

Select One Billing E-Bill

Bill by Fax

Email Address required. Please add Fax Number if selecting Bill by Fax.

I , an authorized representative for , approve access to our account for the persons named above. Through the selection of the above options, I agree my company will receive our monthly bill from Delta Dental via the above selected option and will remit payment as selected above.

Signature:

CR-18, Revised: February 2016

Date:

Enrollment/Eligibility Update PLAN TYPE:

DELTA DENTAL PREMIER

DELTA DENTAL PPO

(AS ESTABLISHED BETWEEN EMPLOYER AND DELTA DENTAL)

DELTA DENTAL PREMIER - CHOICE

DELTA DENTAL PPO - PLUS PREMIER

DELTA DENTAL PPO - CHOICE

DELTA DENTAL PPO - PLUS PREMIER “ELITE”

DELTA DENTAL PPO - CHOICE ADVANTAGE

www.DeltaDentalOK.org

DELTA DENTAL PPO - POINT OF SERVICE

SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS, EXPLANATION OF CODES AND PRIVACY POLICY STATEMENT. LOCATION CODE

GROUP#/SUBGROUP#

Employer: __________________________________________________ Subscriber Information: (please complete in ink for enrollment/eligibility updates) SUBSCRIBER NAME (LAST)

(FIRST)

(M.I.) SUFFIX SEX

MARITAL STATUS

M SUBSCRIBER SOCIAL SECURITY NUMBER

FULL-TIME HIRE DATE

BIRTH DATE

COVERAGE EFFECTIVE DATE

F

M

S

STATUS

ADDRESS

Active

COBRA

Retiree

Surviving Dep.

Other: __________________ CITY

STATE

ZIP

CHECK HERE IF THIS IS A NEW ADDRESS

E-MAIL: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Enrollment/Eligibility Update Information: EFFECTIVE DATE OF UPDATE/CHANGE/TERMINATION: TYPE OF ENROLLMENT/ELIGIBILITY UPDATE: NEW ENROLLMENT COBRA ELECTION

REINSTATEMENT TERMINATION OF BENEFITS

OPEN ENROLLMENT DECLINE

-

CHANGE IN CURRENT ENROLLMENT STATUS FOR:

SUBSCRIBER

DEPENDENTS

REASON FOR CHANGE: DIVORCE

TERMINATION OF EMPLOYMENT AS OF ______ - ________ - ____________

-

ADOPTION

MARRIAGE

NAME CHANGE

LEGAL GUARDIANSHIP

OTHER_______________________________________________________________

TO: GROUP#/SUBGROUP#

GROUP TRANSFER-GROUP#/SUBGROUP#

Dependent Enrollment/Eligibility Update Information: (please complete for spouse and/or dependent children for enrollment/eligibility update) SPOUSE NAME (LAST)

(FIRST)

(M.I.) SUFFIX

SEX MALE

SOCIAL SECURITY NUMBER

FEMALE

BIRTH DATE

DEPENDENT CHILD NAME (LAST)

(FIRST)

(M.I.) SUFFIX

SEX MALE

SOCIAL SECURITY NUMBER

FEMALE

BIRTH DATE DISABLED*

DEPENDENT CHILD NAME (LAST)

(FIRST)

(M.I.) SUFFIX

SEX MALE

SOCIAL SECURITY NUMBER

FEMALE

BIRTH DATE DISABLED*

DEPENDENT CHILD NAME (LAST)

(FIRST)

(M.I.) SUFFIX

SEX MALE

SOCIAL SECURITY NUMBER

FEMALE

BIRTH DATE DISABLED*

DEPENDENT CHILD NAME (LAST)

(FIRST)

(M.I.) SUFFIX

SEX MALE

SOCIAL SECURITY NUMBER

FEMALE

BIRTH DATE DISABLED*

WARNING: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, provides false information herein and makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony. By signing this form, I agree to continue enrollment as provided by the contract between my Employer and Delta Dental of Oklahoma and acknowledge I have read the privacy policy detailed on the back of this form.

Subscriber’s Signature: ______________________

Date: ____ I-DD-ENROLL - 02/16

P lease read the following information carefully before completing the other side of this form. You should fill out this form if you are enrolling for coverage or updating/changing any information from an earlier enrollment. If you have any questions about filling out this form, your human resources or personnel department can help you.

S ubs c riber Information - T his s ection mus t be completed in order to proces s your enrollment or update your records . All information in this s ection s hould apply to you, the primary s ubs criber. P leas e print clearly in ink. F ull-T ime Hire Date:

T he date you were hired with your employer.

C overage E ffec tive Date:

T he date Delta Dental coverage takes effect for you (and/or your dependents , if enrolled).

S tatus Definitions (P leas e s elect only one s tatus ) A c tive

You are an eligible s ubs criber.

R etiree

You are retired and your employer continues to provide you with dental benefits .

C OB R A

You are no longer an active s ubs criber but you have continued coverage under C OB R A. P leas e c hec k with your human res ourc es or pers onnel department for information regarding C OB R A .

S urviving Dep.

T he s urviving s pous e or child of a deceas ed s ubs criber to whom the employer continues to provide benefits other than under provis ions of C OB R A.

E nrollment/E ligibility Update Information - T his s ection s hould only be completed if your are: (1) enrolling yours elf or a family member for the firs t time or (2) if your benefits were terminated and are not being reins tated or (3) if you are making changes to your current enrollment information. New E nrollment:

C heck for firs t time enrollment for yours elf or your eligible dependents .

R eins tatement:

C heck for reins tatement coverage for yours elf or your eligible dependents .

Termination of B enefits :

C heck only if you are terminating Delta Dental coverage for yours elf or a family member.

G roup Trans fers :

Mus t be completed when you are trans ferring from one s ubgroup to another. (All dependents will trans fer)

Dependent E nrollment/E ligibility Update Information - T his s ection s hould be completed when: (1) enrolling dependents or (2) if you are s ubmitting updates /changes to Delta Dental enrollment. (P leas e include both firs t and las t names of any individuals for whom you are enrolling or s ubmitting an update or change). * Dis abled:

Your permanently dis abled dependent child. (R equires s ubmis s ion of medical s tatement)

Delta Dental of Oklahoma P rivac y P olic y All companies part of the Delta Dental of Oklahoma family of companies (referred to in this Privacy Policy as “Delta Dental”) believe that personal information collected about our customers, subscribers, potential customers, and proposed subscribers (referred to collectively in this Privacy Policy as “Customers”) must be treated with the highest degree of confidentiality. For this reason and in compliance with the Gramm-Leach-Bliley Act of 1999, Delta Dental has developed a Privacy Policy that applies to all employees, officers, directors, agents, brokers, and to any other transaction Delta Dental has which may contain your confidential information. Financial companies are able to choose how they share your personal information, however Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. Information We Collect - We collect and maintain personal, nonpublic information we receive from Customers directly, through applications, enrollment forms, check, credit or debit card payments, insurance claims, and our website. We also collect your personal information from other companies. The types of personal information we collect and share depend on the product or service you have with us. This information can include your name, address, social security number, date of birth, transaction and claim history, medical information, and checking account information. Utilization Of Information - Delta Dental has, and will continue to utilize non-affiliated third parties to conduct certain functions of our business in order to provide our Customers with services and products. These functions include processing your requests, claims and transactions, maintaining your account(s), providing information about new products, responding to court orders and legal investigations, reporting to credit bureaus, and to comply with Federal and State Laws. The information Delta Dental uses to provide a service cannot be restricted by our Customers. However, Delta Dental is able to limit this information on your behalf under HIPAA. Federal law gives consumers the right to limit information sharing in relation to affiliates' everyday business purposes, information about your creditworthiness, affiliates using your information to market to you, and nonaffiliates using your information to market to you. In addition, state laws and other individual companies may give you additional rights to limit sharing. Delta Dental does not have any affiliates, nor do we share information with non-affiliates for marketing purposes. When you are no longer our Customer, we will continue to share your information as described in this notice. Our Security - To protect your personal information from unauthorized access and use, we maintain physical, electronic, and procedural safeguards that comply with Federal Law, including computer safeguards and secured files and buildings. We consider nonpublic personal information to be confidential, and treat it as such. The personnel who have access to this information are trained in proper handling of such information. Employees who violate this strict level of confidentiality are subject to our disciplinary process. While we do make available certain nonpublic personal information to non-affiliated third parties in order to service Customer accounts, all information is strictly governed by confidentiality and security agreements to protect our Customers. Therefore, our Customer’s confidential information is protected. If the group plan is terminated or you terminate your coverage, Delta Dental will adhere to the information practices as described in this notice. If you have any questions about our Privacy Policy, please do not hesitate to contact your Delta Dental representative at 800-522-0188 (Toll Free) or 405-607-2100 (OKC Metro). Under no circumstances will we sell information about our Customers or their account to any unaffiliated company, group, or individual without our Customer’s permission.

Federally Compliant Dental Plans   Delta Dental PPO‐Plus Premier Federally Compliant Dental plans – For the 2016 plan year, Delta Dental has two  Federally Compliant Plans designed to meet ACA Pediatric Dental Essential Health Benefit standards. Our plans include  the Delta Dental PPO and Premier networks for maximum network access.    Federally Compliant Pediatric Plans for Groups. Individuals are eligible for coverage to age 19 only.    Plan Information:  Annual Maximum Out‐of‐Pocket:  for one covered person to age 19  Annual Maximum Out‐of‐Pocket:  for two or more covered persons to age 19  Annual Deductible  

High Option 

Low Option 

$350 

$350 

$700 

$700 

$25 per person 

$100 per person 

  Co‐Insurance – The percentage you will pay for covered services  Plan Information:  Preventive & Diagnostic Services  Basic Services  Major Services  Medically Necessary Orthodontic Services*      

Co‐Insurance – High Option    0%  No Deductible  20%  $25 Annual Deductible applies  50%  $25 Annual Deductible applies  50%  No Deductible 

Co‐Insurance – Low Option    0%  $100 Annual Deductible applies  40%  $100 Annual Deductible applies  50%  $100 Annual Deductible applies  50%  No Deductible 

Benefits are based on the State Children’s Health Insurance Program (SCHIP) guidelines. Special processing policies, limitations  and exclusions will apply for medically necessary procedures.  Deductibles and Co‐Insurance will apply to Maximum Out‐of‐Pocket.  Maximum Out‐of‐Pocket does not apply to out‐of‐network services. 

  * Medically Necessary – Orthodontic treatment and/or services are only covered with orthognathic surgery cases or certain     designated syndromes or genetic disorders such as cleft palate. Benefits are only allowed for medically necessary orthodontic     services to help correct severe handicapped malocclusions caused by cranio‐facial orthopedic deformities involving teeth. 

  Coverage Type 

Monthly Rates – High Option 

Monthly Rates – Low Option 

One Covered Person to age 19 

$30.51

$18.80

Two Covered Persons to age 19 

$61.02

$37.60

Three or more Covered Persons to age 19 

$91.53

$56.40

Federally Compliant Dental Plans Delta Dental Program of Benefits for PPO – Plus Premier Federally Compliant Plans  Delta Dental of Oklahoma’s benefits consist of Preventive & Diagnostic Services, Basic Services, Major Services and Medically  Necessary Orthodontic Services. The benefits listed below are not a complete list. Limitations to benefits can be found in the  Summary Plan Description:   

Preventative & Diagnostic Services (Class I Benefits):   Oral evaluation   Routine prophylaxis, including cleaning and polishing   Bitewing and periapical x‐rays   Full‐mouth x‐rays   Topical application of fluoride for eligible children only   Topical application of sealants for eligible children only, limited to permanent first and second molars free of caries and  restorations on the occlusal surface   

Basic Services (Class II Benefits):   Amalgam and composite fillings   Stainless steel crowns for eligible children only when the natural teeth cannot be restored with another filling material   Endodontics – includes pulpal therapy and root canal treatment   Oral Surgery – non‐surgical extractions; medically necessary, non‐prophylactic (diseased) third molar non‐surgical  extractions; incision and drainage of abscess.   Periodontics – procedures performed for the treatment of diseases of the gums and supporting structures of the teeth,  limited to root planing and scaling   Anesthesia – Nitrous oxide/analgesia benefits are limited to invasive procedures (procedures that penetrate the hard or  soft tissue). Nitrous oxide/analgesia is not payable with evaluations and cleanings.   

Major Restorative (Class III Benefits):   Major Restorative – provides porcelain or cast restorations (other than stainless steel) when teeth cannot be restored with  another filling material   Prosthodontics – procedures for construction of fixed bridges, partial dentures and complete dentures   Oral Surgery Services – Surgical extractions; medically necessary, non‐prophylactic (diseased) third molar surgical  extractions; and other oral surgical procedures   Occlusal guards are a benefit by report for eligible children only when used to prevent the destructive force of bruxism for  periodontal purposes. This is a benefit if the eligible child has periodontal coverage and has had periodontal therapy or is  undergoing therapy.   

Medically Necessary Orthodontics (Class IV Benefits):   Orthodontic Benefits are available only with orthognathic surgery cases or certain designated syndromes or genetic  disorders such as cleft palate. Benefits are only allowed for medically necessary orthodontic services to help correct severe  handicapping malocclusions caused by cranio‐facial orthopedic deformities involving the teeth.    Orthodontic coverage  is a benefit provided for dependent children only to the age of 19.   

Delta Dental of Oklahoma Post Office Box 54709 Oklahoma City, OK 73154 - 1709

www.DeltaDentalOK.org

$30.51 $30.51

Low Option $18.80 $18.80

$30.51 $61.02 $91.53

Low Option $18.80 $37.60 $56.40 Low Option

to age 19 Person

Oct 2015)

(Please complete the reverse side of this Application)

For Covered Person(s) age 19 and older only (Family Plan only) Maximum Plan Year Benefit Payment: $1,500 Specific Benefit Limitation Period(s): Class II = 6 months Class III = 12 months For Covered Person(s) under age 19 Maximum Out of Pocket Cost per Benefit Year: $350 - 1 Covered Person

$700 - 2 or more Covered Person(s)

Minus Ineligible ELIGIBILITY/ENROLLMENT: Total Employees Explain Ineligible Employees, e.g., part-time, etc.: Employer Contribution to Cost of Plan:

Employee Cost

% or $

= Total Eligible Employees Dependent Cost

% or $

Waiting Period for New Enrollees: ____________________________________________________________________________ (Effective date cannot exceed 90 days from date of hire) Please indicate to whom the new group packet (plan agreement, ID cards, etc.) should be shipped. Form 5500 Information Required?

Yes

No

Producer

Group

If “Yes”, reporting timeframe required:

Self-Insured Accounts Only Administrative Fee: $ Per Enrolled Employee Per Month Operating Fund Deposit (please include prefunding check with application):

% of Paid Claims Per Month

Claims Reimbursement Options:

Weekly Wire Transfer Weekly Draft

Bi-weekly Wire Transfer Bi-weekly Draft

Monthly Wire Transfer Monthly Draft Monthly Check

Administrative Fee Payment Options:

Weekly Wire Transferr Weekly Draft

Monthly Wire Transfer Monthly Draft

Monthly Draft Monthly Check

PRODUCER/CONSULTANT INFORMATION: Please complete the information requested below. Social Security No. Federal Tax ID No. Mailing Address

Producer/Consultant Agency Street Address Business Phone No. ( E-Mail Address

)

Fax No. ( ) Website Address

Producer/Consultant Fee Payment Options (if applicable):

EFT To Producer/Consultant

EFT To Agency

HOLD HARMLESS Delta Dental has not reviewed the employer's request for plan coverage nor designed the group plan to meet any federal requirements for Discriminatory Employee Benefit Plans. Said plan may not be in compliance with criteria established for Discriminatory Employee Benefit Plans, and employer holds Delta Dental Plan of Oklahoma harmless if said plan fails to meet any such requirements.

All information above is true and correct to the best of my knowledge.

I have reviewed the benefits and eligibility requirements as stated in this Group Application and accept them.

Producer/Consultant’s Signature

Employer's Authorized Signature

_________________________

Date

Title

Please mark if the following is submitted with this signed application:

Form No. 4100.1 (Rev. Oct 2015)

Date

Enrollment forms Electronic enrollment data Check for first month’s premium

CONFIDENTIAL

Delta Dental PPO Plus Premier Federally Compliant Plans Enrollment Form www.DeltaDentalOK.org

Employee Name: ________________________ ____________________________________ Date of Birth: ________________ Sex:

M

F

Street Address: ___________________________________________ City: __________________ _________________ State: ______ Zip: _________ Social Security #: ________________________ E-mail: ______________________________________________________________ Group/Subgroup

SEE REVERSE SIDE OF THIS FORM FOR PRIVACY POLICY STATEMENT

Location Code

Employer : _______________________________________________________ Please list all Covered Persons under the age of 19 to be enrolled. Each Covered Person's SSN MUST be provided Covered Person: _______________________________________ Sex: ______ SSN: ___________________ Date of Birth: ___________ Covered Person: _______________________________________ Sex: ______ SSN: ___________________ Date of Birth: ___________ Covered Person: _______________________________________ Sex: ______ SSN: ___________________ Date of Birth: ___________ Covered Person: _______________________________________ Sex: ______ SSN: ___________________ Date of Birth: ___________ Covered Person: _______________________________________ Sex: ______ SSN: ___________________ Date of Birth: ___________ Covered Person: _______________________________________ Sex: ______ SSN: ___________________ Date of Birth: ___________

Program Selec on (Choose One)

Pediatric Only Low Plan

Pediatric Only High Plan Program Type (Choose One)

Enrollment/Eligibility Update Informa on: Eligibility Date

Program Type

Your Cost

ctive Date of Update/Change/Termination

Mail to:

Your Cost

(Choose One)

One Covered Person $ 30.51 per month

One Covered Person $ 18.80 per month

Two Covered Persons $ 61.02 per month

Two Covered Persons $ 37.60 per month

Three or more Covered Persons

Three or more Covered Persons

$ 91.53 per month

Group/Subgroup Transfer From Group/Subgroup

E

To Group/Subgroup

$ 56.40 per month

Change in Status for: Subscriber Reason for Change: Name Change New Address Adop on/Guardianship* Termin on of Coverage

Dependent(s) Marriage Divorce Other__

Delta Dental of Oklahoma A n: Health Care ReformTeam PO Box 54709 Oklahoma City, OK 73154

Fax to: 1-405-607-2199

Email to: [email protected]

*Legal Documents Must Be Submitted for Update/Change

Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, provides false inform on herein and makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading inform

on is guilty of a felony.

By signing this form, I agree to con nue enrollment as provided by the contract between my Employer and Delta Dental of Oklahoma and acknowledge I have read the privacy policy on the back of this form.

Applicant Signature:_______________________________________________________ Date: _________________________________ PedEnroll (10/15)

TURN OVER/NEXT PAGE >>

Delta Dental of Oklahoma Privacy Policy All companies part of the Delta Dental of Oklahoma family of companies (referred to in this Privacy Policy as “Delta Dental”) believe that personal information collected about our customers, subscribers, potential customers, and proposed subscribers (referred to collectively in this Privacy Policy as “Customers”) must be treated with the highest degree of confidentiality. For this reason and in compliance with the Gramm-Leach-Bliley Act of 1999, Delta Dental has developed a Privacy Policy that applies to all employees, officers, directors, agents, brokers, and to any other transaction Delta Dental has which may contain your confidential information. Financial companies are able to choose how they share your personal information; however Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. Information We Collect – We collect and maintain personal, nonpublic information we receive from Customers directly, through applications, enrollment forms, check, credit or debit card payments, insurance claims, and our website. We also collect your personal information from other companies. The types of personal information we collect and share depend on the product or service you have with us. This information can include your name, address, social security number, date of birth, transaction and claim history, medical information, and checking account information. Utilization Of Information – Delta Dental has, and will continue to utilize non-affiliated third parties to conduct certain functions of our business in order to provide our Customers with services and products. These functions include processing your requests, claims and transactions, maintaining your account(s), providing information about new products, responding to court orders and legal investigations, reporting to credit bureaus, and to comply with Federal and State Laws. The information Delta Dental uses to provide a service cannot be restricted by our Customers. However, Delta Dental is able to limit this information on your behalf under HIPAA. Federal law gives consumers the right to limit information sharing in relation to affiliates’ everyday business purposes, information about your creditworthiness, affiliates using your information to market to you, and non-affiliates using your information to market to you. In addition, state laws and other individual companies may give you additional rights to limit sharing. Delta Dental does not have any affiliates, nor do we share information with non-affiliates for marketing purposes. When you are no longer our Customer, we will continue to share your information as described in this notice. Our Security - To protect your personal information from unauthorized access and use, we maintain physical, electronic, and procedural safeguards that comply with Federal Law, including computer safeguards and secured files and buildings. We consider nonpublic personal information to be confidential, and treat it as such. The personnel who have access to this information are trained in proper handling of such information. Employees who violate this strict level of confidentiality are subject to our disciplinary process. While we do make available certain nonpublic personal information to non-affiliated third parties in order to service Customer accounts, all information is strictly governed by confidentiality and security agreements to protect our Customers. Therefore, our Customer’s confidential information is protected. If the group plan is terminated or you terminate your coverage, Delta Dental will adhere to the information practices as described in this notice. If you have any questions about our Privacy Policy, please do not hesitate to contact your Delta Dental representative at 800-522-0188 (Toll Free) or 405-607-2100 (OKC Metro). Under no circumstances will we sell information about our Customers or their account to any unaffiliated company, group, or individual without our Customer’s permission.

Revised 06/2010

For Members

Features & Services Delta Dental of Oklahoma provides numerous tools and services to help you get the most out of your dental benefits. From online services to multiple provider networks, Delta Dental of Oklahoma has your smile covered.

Spotlight

TM

Spotlight is online, real-time, 24/7 secure access to benefit information you want – when you want it. Our online services provide: • Claims Status • Find a Dentist • Prevent-O-Meter • Oral Health Education and more!

My Mouth Dental procedure codes and tooth numbers can be confusing. That is why we provide a My Mouth chart in Spotlight. This chart is a graphic illustration of your teeth, with color codes that show dental work, as well as an explanation of the procedures performed on each tooth. It is a tool that can help you better understand the dental care you receive.

View My Benefits In order to take full advantage of your dental benefits, you have to have a good understanding of what they are. Spotlight makes that easy with the View My Benefits tool. Here you can see a list of what your dental plan covers and what, if any, limitations apply. You can also view your benefits as a PDF to easily print, save and email, when necessary.

S-04, Revised: 04/27/16

Access Your Explanation of Benefits (EOB) Your EOB is the key to understanding how Delta Dental of Oklahoma pays your claims. Spotlight gives you the freedom to access your EOB before you receive it in the mail. You can also view your history for up to seven years so you don’t have to search for paper documents should you need to revisit a claim.

Print Your ID Card While you don’t have to bring your ID card with you when you visit your dentist, sometimes having it brings peace of mind that your claims will be paid appropriately. With Spotlight, you have 24/7 access to view, print, save or email your ID card directly from your computer.

To register for Spotlight, visit: DeltaDentalOK.org/Spotlight

Multiple Provider Networks Delta Dental offers two of the nation’s largest dental provider networks. Delta Dental Premier consists of more than two-thirds of the nation’s dentists. Delta Dental PPO consists of nearly 50% of the nation’s dentists and typically provides lower out-of-pocket costs.

No Balance Billing If you visit a Delta Dental PPO participating dentist, you are not responsible for any amounts in excess of Delta Dental’s PPO maximum allowable amount. Members enrolled in a Delta Dental Plus Premier plan enjoy no balance-billing with any participating network provider.

Customer Service Our Oklahoma based Customer Service Department is just a phone call away. Customer Service Representatives can be reached at 405-607-2100 or toll free at 1-800-522-0188 and are available Monday through Friday from 7am to 6pm. Oral health tips, our Find a Dentist tool and many other services are available to you 24/7 at DeltaDentalOK.org.

For Members

Mobile Features & Services For quick, on-the-go dental benefits information, there’s the Delta Dental Mobile App. The mobile app is perfect for those benefit questions that arise when you are out and about and need a quick answer right at your fingertips. Our mobile website is another convenient way to access contact information and other valuable resources 24/7.

Mobile App

Mobile Website

Securely Access Benefits

Contact Information

With Delta Dental’s free mobile app you can stay up-to-date on coverage information, plan type, benefit levels, contact information, deductibles and maximums. You can check the status of your most recent dental claims, view details and even email claim information for both you and your dependents under age 18. In order to securely access this information, be sure to register on the DeltaDental.com website and login using your mobile device.

If you ever have a question about your dental benefits plan, how we paid a claim or simply need clarification, we are just a phone call or email away. Our contact information for Customer Service, Sales and Client Relations, to name a few, is easily located on the DeltaDentalOK.org mobile website.

Additional Tools The mobile app provides a comprehensive Find a Dentist tool where you can search all networks. This field will automatically default to your plan if you are logged in but is available to all users without logging in as well. You can also view your mobile ID card or even email your card to your dental office or dependents. The mobile app comes complete with a musical toothbrush timer so you and your dependents can stay up-to-date with your oral wellness routine.

S-04, Revised: 4/27/16

Valuable Resources With multiple avenues to find a dentist and brush up on your oral wellness tips, our mobile website makes keeping up with your oral wellness routine easy.

See better – live better

Delta Dental vision provided by EyeMed

Locate a provider

Your eyes say a lot about you – from your emotions to vision and your overall health. And, when you’re proactive about protecting your eyes, the impact is clear.

You love choices - and so do we. That’s why our network has thousands of independent doctors and retail providers.

Regular eye exams not only correct vision problems, they also can reveal early warning signs of more serious health conditions such as hypertension, cardiovascular disease and diabetes. So, schedule exams annually and you’ll be set on a path to better health. Keep on saving You can use your EyeMed discount as often as you like, all year long, on nearly all your vision care purchases at EyeMed’s participating providers.

Schedule an appointment Call ahead or stop by one of the many providers that offer walk-ins. Most also have evening and weekend hours to fit any schedule. Show your ID card When you arrive, let the provider know you have an EyeMed discount through Delta Dental.

Visit deltadental.com to learn more Need to locate a provider? Want to learn about vision wellness? Visit deltadental.com.

Member/Patient Services: 1.866.723.0391 ACCESS DISCOUNT PLAN

DELTA DENTAL Discount Plan Number 9231093

Signature: Please note your discount cannot be combined with any other discounts, coupons or promotional offers. ASSET NUMBER

This is not insurance. Dependents are eligible.

deltadental.com

Please detach carefully at perforation and keep card in your wallet.

Delta Dental Discount plan Access network Discounted exam and a defined materials discount

Vision care services

Member cost

Exam and dilation as necessary

$5 off routine exam $10 off contact lens exam

Complete pair of glasses purchase*: Frame, lenses and lens options must be purchased in the same transaction to receive full discount. Standard plastic lenses: Single Vision Bifocal Trifocal

$50 $70 $105

Frames

35% off retail price

Lens options: UV treatment Tint (solid and gradient) Standard plastic scratch coating Standard polycarbonate Standard progressive lens (Add-on to bifocal) Standard anti-reflective coating Other add-ons and services

$15 $15 $15 $40 $65 $45 20% off retail price

Contact lens materials: (Discount applied to materials only) Disposable Conventional

0% off retail price 15% off retail price

Laser vision correction**: LASIK or PRK

15% off retail price or 5% off promotional price

Frequency: Examination Frame Lenses Contact lenses

Unlimited Unlimited Unlimited Unlimited

THIS IS NOT INSURANCE *Items purchased separately will be discounted 20% off of the retail price. **Since LASIK and PRK vision corrections are elective procedures, performed by specially trained providers, this discount may not always be available from a provider in your location. For a location near you and the discount authorization, please call 1.877.5LASER6. Member will receive a 20% discount on those items purchased at participating providers that are not specifically covered by this discount. The 20% off discount does not apply to EyeMed providers' professional services or contact lenses. Retail prices may vary by location. All discounts cannot be combined with any other discounts or promotional offers. This discount design is offered with the EyeMed Access panel of providers.

Limitations/Exclusions:

EyeMed Member/Patient Services: Visit eyemed.com or call the number on the front of this card. EyeMed Doctors/Providers Only: Visit eyemed.com to receive plan information or authorization online or call 1.800.521.3605.

• Orthoptic or vision training, subnormal vision aids and any associated supplemental testing • Medical and/or surgical treatment of the eye, eyes or supporting structures • Corrective eyewear required by an employer as a condition of employment and safety eyewear unless specifically covered under plan • Services provided as a result of any Worker’s Compensation law • Discount is not available on those frames where the manufacturer prohibits a discount

Visit eyemedvisioncare.com/deltad for more information or to locate a provider near you.

SPOTLIGHT

ANSWERS ARE ALWAYS AT YOUR FINGERTIPS New subscribers to Delta Dental plans tend to have a lot of questions. SPOTLIGHT is Delta Dental of Oklahoma’s online portal for dental plan subscribers that answers most of those questions before they are even asked.

Since SPOTLIGHT allows 24/7 access, subscribers can manage their dental benefits at the time and place of their choosing.

Here are a few ways you can use Spotlight any time any day: • Print your dental benefits ID card • Review your claims status and claims history • Review your benefit plan information • Review your eligibility for treatment • Find a Delta Dental network dentist • Access a Delta Dental claim form (for out-of-network treatment)

REGISTER TODAY! Visit DeltaDentalOK.org/spotlight to register for your exclusive login information to access Spotlight any time any day.