The MARS Associates 2015–17 Retiree Dental Plan Coverage Effective September 1, 2015–August 31, 2017*
deltadentalco.com
How the Plan Works
At Delta Dental of Colorado, we understand the connection between good oral health and good overall health. That’s why we’re excited to offer MARS Associates three choices of dental plans. All plans are voluntary, so you have the choice to elect coverage or not. In order for your spouse or family members to receive coverage, you must be enrolled. All family members must choose the same plan design.
Three Plan Options
Delta Dental of Colorado is offering three plans for you to choose from: the High Option, the Medium Option, and the Low Option. Please make your selection carefully. Review the plan details for each option on the opposite page and on the enclosed plan comparison.
Enrollment Guidelines
Individuals who have recently retired and are members of MARS Associates may elect individual or family coverage. You must enroll within 60 days of retirement (or the end of COBRA coverage). If you are not joining the plan within 60 days of retirement (or the end of COBRA coverage), the next opportunity to enroll is during the open enrollment period the following year. Important Note: The plan options provided include waiting periods. If you join within 60 days of retirement (or the end of COBRA coverage), the waiting periods will be waived. Please provide proof of date of retirement (or end of COBRA coverage) along with your enrollment form to waive the waiting periods.
Enrolling in a Plan
Review the plan options and rates. When you are ready to enroll, complete the enclosed Enrollment & Payment Authorization form for yourself and the family members that you would like to cover. Be sure to select a plan option. Mail your Enrollment & Payment Authorization form to: Delta Dental of Colorado Attn: Group Administration PO Box 5468 Denver, CO 80217-5468
Additional Information
Shortly after we receive and process your complete Enrollment & Payment Authorization form, you will receive your Delta Dental benefits booklet and ID card. This information provides a brief description of services covered under your contract. It does not list services that are limited or excluded from coverage. Your benefit booklet provides a more complete explanation of coverage, including limitations and exclusions. If differences exist between this summary of benefits and your summary plan description benefit booklet, the benefit booklet governs.
*The effective date of September 1, 2015, applies to those who enroll during the current open enrollment period. Otherwise, enrollment will be effective on the first day of the following month, when received by the 20th of previous month.
MARS ASSOCIATES 2015–17 RETIREE DENTAL PLAN OPTIONS 1. High Option — Delta Dental PPOSM (available in all states): Those who select the High Option PPO plan may use any licensed provider, including those who do not participate in Delta Dental’s networks. However, you will have the lowest out-of-pocket costs when you choose a Delta Dental PPO provider. If you see a Delta Dental Premier® provider, you will still save, but not as much. If you see a non-participating provider, you will be responsible for charges in excess of Delta Dental’s allowed amount (called balance-billing). Non-participating providers can charge any amount, so choosing a non-participating provider could mean significant out-of-pocket costs for you. DELTA DENTAL’S PPO AND PREMIER NETWORKS INCLUDE NEARLY 3,200 PROVIDERS IN COLORADO AND MORE THAN 145,000 NATIONWIDE. 2. Medium Option — Delta Dental Exclusive Panel Option (EPO) a feature of Delta Dental PPOSM (available in all states): With the Medium Option EPO plan, you must receive care from a provider who participates in the Delta Dental PPO network. This network includes more than 2,100 providers in Colorado and nearly 90,000 nationwide. If you receive treatment from a non-PPO dentist, you will be responsible for all fees charged. You do not need to select a specific provider under this plan. You may use any provider in the Delta Dental PPO network, and you may change providers as often as you like. 3. Low Option — Delta Dental Patient Direct® (available only in Colorado): Patient Direct is a dental discount plan, not insurance. The plan’s low monthly premiums give you significant savings on many dental procedures. There are no annual maximums, no deductibles, no waiting periods, and no claims to file. To get these discounts, you must see a provider who participates in the Patient Direct network, which includes more than 900 providers. All family members must visit the same provider. If you receive care from a specialist, you will receive an approximate 10% discount from the specialist’s usual fee.
Visit us at deltadentalco.com to: • Find a provider • View benefits • Print ID cards
• Check claim status • Assess your oral health risk
• View wellness resources • And much more
Or download our mobile app for iPhone and Android.
Dental Plans to Keep You Healthy and Smiling Delta Dental of Colorado is the state’s leading dental benefits company and the only one based in Colorado. Unlike most carriers, we focus on just one thing — dental insurance. We provide our more than one million members with the convenience of local customer service backed by a national network of dental providers. In addition, we are a nonprofit company with a mission to improve oral health in Colorado. Since 1958, we have offered high-quality, cost-effective dental plans to help you stay healthy and smiling.
Contact Us Delta Dental of Colorado 5482 South Ulster Street, Suite 800 | Denver, Colorado 80237 | deltadentalco.com Customer Relations Toll-free: 1-800-610-0201 | Monday–Friday 8 a.m. to 6 p.m. Mountain Time Email:
[email protected] Patient Direct Website: https://www.deltadentalco.com/PatientDirect.apsx
Re: Your Information Request about Delta Dental Plan Options
Dear MARS Association Retiree: Thank you for your inquiry regarding the Delta Dental of Colorado dental insurance plans offered through your MARS Associates membership. Delta Dental of Colorado is offering three plan options with enhanced benefits, at very reasonable rates. Information on plan options is posted on MARS Association’s website (marsretirees.org). Please Note: You must enroll within 60 days of retirement (or at the end of your COBRA coverage); otherwise, you must wait until the next annual open enrollment period. If you had previous dental insurance and enroll in the Delta Dental MARS Associates plan within 60 days of your coverage termination, the waiting periods will be waived. Please include a note on the enrollment form if you had previous dental coverage and provide proof of coverage to Delta Dental along with your enrollment application. If you have questions, please contact me directly. My contact information is below.
Thank you,
Jeff Satterwhite, Account Specialist Direct: 303-889-8683 Toll-free: 1-800-610-0201, ext. 683 Email:
[email protected]
September 1, 2015–August 31, 2017
Delta Dental of Colorado Retiree Dental Plans for MARS Associates
Network Access Contract Year Annual Maximum Deductible per Person per Contract Year
Delta Dental Patient Direct® (Low Option) Group #9000
Delta Dental Exclusive Panel Plan (Medium Option) Group #9001
Delta Dental PPOSM (High Option) Group #9002
Patient Direct Network
PPO Network Only
Any Licensed Provider
Unlimited
$1,000
$1,500
None
$75
$50
Delta Dental pays 100% of PPO provider’s allowable fee. Deductible does not apply.
Delta Dental pays 100% of procedure cost when using a PPO provider; 80% when using a non-PPO provider. Deductible does not apply.
Delta Dental pays 70% of PPO provider’s allowable fee after deductible is met.
Delta Dental pays 80% of procedure cost when using a PPO provider; 50% when using a non-PPO provider after deductible is met.
Covered Services PREVENTIVE SERVICES Oral Exams Limited to 1 in a 6-month period Cleanings Limited to 1 in a 6-month period Fluoride Treatment Limited to 1 in a 12-month period, for children age 15 and under
See fee schedule.
Space Maintainers For children age 13 and under Sealants For children age 14 and under BASIC SERVICES Full-mouth/Panoramic X-rays Limited to 1 in a 60-month period Bitewing X-rays Limited to 1 in a 12-month period
See fee schedule.
Simple Extractions Fillings
MAJOR SERVICES (12-MONTH WAITING PERIOD*) Periodontics (Gum Disease Treatment) Endodontics (Root Canals) Surgical Extractions General Anesthesia Denture Relines, Rebases, and Adjustments Repairs to Crowns, Dentures, and Bridges
See fee schedule.
Special Restorative
Delta Dental pays 40% of PPO provider’s allowable fee after deductible is met.
Crowns
Delta Dental pays 50% of procedure cost when using a PPO provider; 40% when using a non-PPO provider after deductible is met.
Complete and Partial Dentures Fixed Bridgework 2014 MARS Retiree Dental Plan Rates Employee Only
$12.75
$34.75
$43.84
Employee + 1 Dependent
$22.75
$66.06
$83.30
Employee + 2 or More Dependents
$32.75
$95.34
$116.83
*Waiting periods are waived for retirees who have had previous dental coverage and enroll within 60 days of retirement or at the end of COBRA coverage. There are no waiting periods for the Low Option. Important Note: This form provides only a brief description of services covered under your contract and does not list those services that are limited or excluded from coverage. Your benefit booklet provides a more complete explanation of your coverage, including limitations and exclusions. If differences exist between this summary of benefits and your benefit booklet, the benefit booklet will govern.
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