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DeltaCare USA DHMO Standard

Under the DeltaCare® USA program, many services are covered at no cost, while others have copayments (amount you pay your contract dentist) for certain benefits.

DeltaCare USA Plans - DHMO Dental Plans

Dental services that are not performed by your selected in-network participating (contracted) dentist, or are not covered under provisions for emergency care below, must be preauthorized by us to be covered by your DeltaCare USA program.

The program is designed to encourage regular visits to the dentist by having no copayments (fees you pay to the contract dentist) on most diagnostic and preventive benefits.

Your participating in-network (contracted) dentist will coordinate your specialty care needs for oral surgery, endodontics or periodontics with an approved in-network (contracted) specialist. There is no additional charge to you for receiving care from a specialist. If there is no participating specialist within your service area, a referral to an out-of-network specialist will be authorized at no extra cost, other than the applicable copayment.

Summary of Benefits

Exam

You Pay
Office Visit $5.00
Periodic Oral Evaluation $0.00
Limited Oral Evaluation – Problem focused $0.00
Comprehensive Oral Evaluation $0.00
X-Rays You Pay

Intraoral – Complete Series, including bitewings

$0.00

Intraoral – Periapical first film

$0.00

Intraoral – Periapical each additional film

$0.00

Bitewings – two films

$0.00

Bitewings – four films

$0.00

Panoramic

$0.00
Preventive Services You Pay

Prophylaxis – adult cleaning

$0.00

Prophylaxis – child cleaning

$0.00

Fluoride – child

$0.00

Sealant – per tooth

$0.00
Silver Fillings You Pay

Amalgam, 1 Surface, primary or permanent

$20.00

Amalgam, 2 Surface, primary or permanent

$25.00

White Fillings, Front Teeth

You Pay

Anterior Composite, 1 surface

$35.00

Anterior Composite, 2 surface

$40.00

Onlays and Crowns

You Pay

Crown, All Porcelain

$370.00

Core Build Up

$60.00

Periodontal Care (For Gums)

You Pay

Periodontal Therapy, 4+ teeth/quadrant

$60.00

Periodontal Maintenance

$50.00

Extractions

You Pay
Extraction, erupted tooth or exposed root $20.00

Surgical removal of erupted teeth

$50.00

Orthodontia Care

You Pay

Comprehensive Orthodontic treatment – adolescent (up to 24 months – including xed/removable appliances) to age 19

$2,095.00

Comprehensive Orthodontic treatment – adult (up to 24 months – including xed/removable appliances)

$2,095.00

Pre-orthodontic treatment visit (consult/records/exam)

$35.00

Orthodontic Retention (removal of appliances, construction and placement of retainer(s))

$300.00

Unspecified Orthodontic Procedure – By Report

$250.00

If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern.

 

Plan Details

Frequently Asked Questions

Click on the question to view the answer

How to use your DeltaCare USA Plan:
A list of participating plan providers in Miami-Dade, Broward, Monroe and Palm Beach Counties can be viewed online at www.deltadentalins.com/mdcps. You may also call Customer Service at 1.800.693.2589. Multilingual representatives are available from 8 a.m. to 9 p.m. Eastern Time, Monday through Friday.
How can I make an appointment with my DeltaCare USA dentist?
You may schedule an appointment by calling the dental office you selected on or after your effective date of coverage. When you call to schedule your appointment, inform the office that you are a member of the DeltaCare USA dental plan. It will not be necessary to use any claim forms. If you need to cancel your appointment for any reason, please let your provider know twenty-four (24) hours in advance of your scheduled appointment. The Benefits Schedule allows the provider to charge a fee (up to a maximum of $25) for any broken or cancelled appointment without twenty-four (24) hours’ notice.
How long does it take to get an appointment with a DeltaCare USA dentist?
Two to four weeks is a reasonable amount of time to wait for a routine, non-urgent appointment. If you require a specific time, you may have to wait longer. Most DeltaCare USA dentists are in private group practices, which means greater appointment availability and extended office hours.
Who is an eligible dependent for this coverage?
Eligible dependents for this plan include:

  • Spouse/Domestic Partner
  • Unmarried natural children, adopted children, and stepchildren under your or your spouse’s legal guardianship until the end of the calendar year in which the child reaches age 26
  • Children of a Domestic Partner, as long as the Domestic Partner is also covered.

NOTE: Children may be covered under this plan until the end of the calendar year in which the child reaches age 26, provided he/she is unmarried and resides in your home and depends upon you for support, or is registered as a full-time or part-time student. Children with a mental or physical handicap are also eligible for coverage beyond the age of 26.

Can I change my contract dentist?
You may change contract dentists by notifying us either by phone or in writing, or by visiting our website, www.deltadentalins.com/mdcps. If you contact us by the 21st of the month, the change will become effective the first of the following month.
What if I need the services of a Specialist?
Your participating dentist will coordinate your specialty care needs for oral surgery, endodontics or periodontics with an approved contract specialist. There is no additional charge to you for receiving care from a specialist. If there is no contract specialist within your service area, a referral to an out-of-network specialist will be authorized at no extra cost, other than the applicable copayment.
What can I do if I have questions about the treatment plan prescribed by my General Dentist?
Call DeltaCare Customer Service at 1.800.693.2589 Monday through Friday 8 a.m. – 9 p.m. ET.
What if I'm currently seeing a dentist under one plan and I change plans to the DeltaCare USA Plan, but would like to maintain the same dentist?
As long as the dentist is part of the DeltaCare USA network and is accepting patients, you may select the facility as your primary dentist. If the facility is not open to new membership, you will have to select another participating provider.
How can I receive emergency care within the service area?

Under your DeltaCare USA program, you and your eligible dependents are covered for out-of-area dental emergencies (35 or more miles from your contract dentist). Your program pays up to $100 for out-of-area emergency dental expenses per emergency for each enrollee.

How can I receive emergency care for out-of-area?
Under your DeltaCare USA program, you and your eligible dependents are covered for out-of-area dental emergencies (35 or more miles from your contract dentist). Your program pays up to $100 for out-of-area emergency dental expenses per emergency for each enrollee.
What if I have questions about my DeltaCare USA program?
Call Customer Service at 1.800.693.2589. We have multilingual representatives available from 8 a.m. to 9 p.m. Eastern time, Monday through Friday. Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals.
Are pre-existing dental conditions and work in progress covered?

Treatment for pre-existing conditions, such as extracted teeth, is covered under the DeltaCare USA program. However, benefits are not provided for any dental treatment started before joining the program (that is, work in progress, such as preparations for crowns, root canals and impressions for dentures). Orthodontic treatment in progress may be covered for new DeltaCare USA enrollees. See the “Limitations and Exclusions of Benefits.”

How to use dental benefits:
A list containing the Select Panel Providers in Miami-Dade, Broward, Monroe and Palm Beach Counties can be viewed online at www.deltadentalins.com/mdcps. You may call the DeltaCare Customer Services Department at 1.800.693.2589 to verify your dentist’s continued participation in your selected plan.

Limitations/Exclusions

Limitations of Benefits

  1. The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and Copayments.
  2. Any procedures not specifically listed as a covered benefit in this Plan’s Schedule A are available at 75% of the filed fees of the Enrollee’s selected Contract Dentist or Contract Specialist, provided the services are included in the treatment plan and are not specifically excluded.
  3. Dental procedures or services performed solely for cosmetic purposes or solely for appearance are available at 75% of the filed fees of the Enrollee’s selected Contract Dentist or Contract Specialist, unless specifically listed as a covered benefit on Schedule A.
  4. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $25.00 above the listed Copayment for each of these services after the sixth unit has been provided.
  5. General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241).
  6. The removal of asymptomatic third molars is not a covered benefit unless pathology (disease) exists, however it is available at 75% of the Enrollee’s selected Contract Dentist or Contract Specialist’s filed fees.
  7. Benefits provided by a pediatric Dentist are limited to children, through the end of the month that the dependent child turns age eight.
  8. The cost to an Enrollee receiving orthodontic treatment whose coverage is canceled or terminated for any reason will be based on the Contract Orthodontist’s filed fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged.
  9. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.

Exclusions of Benefits

  1. Any procedure that has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or is inconsistent with generally accepted standards for dentistry.
  2. Services solely for cosmetic purposes, with the exception of procedure D9975 (External bleaching for home application, per arch), or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth abnormalities.
  3. Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age.
  4. Lost, stolen or broken appliances including, but not limited to, full or partial dentures, space maintainers, crowns, fixed partial dentures (bridges) and orthodontic appliances.
  5. Procedures, appliances or restoration if the purpose is to change vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ) with the exception of procedures D9951 and D9952 as shown on Schedule A.
  6. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or xed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures.
  7. Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant.
  8. Consultations or other diagnostic services for non-covered benefits.
  9. Dental services received from any dental facility other than the assigned Contract Dentist or an authorized dental specialist (oral surgeon, endodontist, periodontist or Contract Orthodontist) except for Emergency Services as described in the Contract and/or Evidence of Coverage.
  10. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility.
  11. Over-the-counter drugs; prescription drugs not administered by the Enrollee’s selected Contract Dentist or Contract Specialist.
  12. Dental expenses incurred in connection with any dental procedure started before the Enrollee’s eligibility with the DeltaCare USA Program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken and orthodontics unless qualified for the orthodontic treatment in progress provision.
  13. Changes in orthodontic treatment necessitated by accident of any kind.
  14. Myofunctional and parafunctional appliances and/or therapies.
  15. Composite or ceramic brackets, lingual adaptation of orthodontic bands, Invisalign and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.
  16. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.
  17. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare.
  18. Dental services required while serving in the Armed Forces or any country or international authority.
  19. Dental services considered experimental in nature.
  20. Orthognathic surgery.
  21. Any dental services, or appliances, which are determined to be not reasonable and/or necessary for maintaining or improving the Enrollee’s dental health, as determined by the DeltaCare USA Contract Dentist.
  22. Treatment of malignancies, cysts, or neoplasms unless specifically listed as a covered benefit on this Plan’s Schedule of Benefits. Any services related to pathology laboratory fees.
Delta Dental
Mon – Fri, 8 a.m. to 9 p.m. ET
Customer Service: 1-800-693-2589
Multilingual Representatives are available.
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Miami-Dade County Public Schools

Office of Risk and Benefits Management
1501 N.E. 2nd Avenue, Suite 335
Miami, Florida 33132
Mon - Fri, 8 a.m. to 4:30 p.m. ET
www.dadeschools.net

Benefits Inquiry:

FBMC Service Center
Mon - Fri,
7 a.m. to 7 p.m. ET
1-855-MDC-PS4U (1-855-632-7748)

Enrollment Helpline:

1-305-995-2777
7 a.m. to 7 p.m. ET /
Seven days a week