As an employee, the OCC Dental Insurance Program offers you the choice of two quality dental options — the PPO option called Delta Dental PPOSM plan and the dental HMO — DHMO option known as DeltaCare® USA plan. Each option is structured differently.
The PPO and DeltaCare USA plans each provide a wide range of preventive, diagnostic, basic and major restorative services as well as orthodontia. Although not required, those enrolled in the PPO plan are encouraged to ask their dentist to obtain a pre-treatment of benefits from Delta Dental before having any major restorative and prosthodontic services performed. Obtaining a pre-treatment will help you avoid any surprises regarding your out-of-pocket costs.
The chart below provides an overview of both options through Delta Dental so that you can compare the benefits.
|DeltaCare USA (DHMO)|
|Plan Pays||You Pay||Plan Pays||You Pay|
|Class I – Diagnostic and Preventive
(exams, x-rays, cleanings)
|Class II – Basic Restorative
(fillings, root canals, simple extractions)
|80%*||20%*||80%*||20%*||Copayments range from $0 - $380|
|Class III – Major Restorative Care
(crowns, wisdom teeth extractions, partials, dentures, implants)***
|60%*||40%*||60%*||40%*||Copayments range from $10 - $415
Optional treatment: limited to implant/abutment supported crowns and dentures
|Class IV – Orthodontia||60%*||40%*||60%*||40%*||Copayments range from $1,150 - $2,100|
|Authorization for specialty care treatment||Preauthorization is not required||Preauthorization is not required||Your DeltaCare USA (DHMO) dentist will coordinate authorization for specialty care treatment†|
|Annual Deductible||$50 per person
$150 per family
|$50 per person
$150 per family
|No annual deductible|
|Annual Maximum (Class I, II and III services)||$2,500||$2,500||No annual maximum|
|Orthodontic Lifetime Maximum||$2,000 for adults and children||$2,000 for adults and children||No lifetime orthodontic maximum|
|Claims||Delta Dental network dentists file claim forms and accept payment directly from Delta Dental||Non-Delta Dental dentists may require payment upfront and may require you to file your own claim for reimbursement||
No claim forms
Pay the listed copayment for covered services at the time of your visit
1 DeltaCare USA is not available in MN and ND. In AK, CT, LA, ME, MS, MT, NH, NC, OK, SD, VT and WY, DeltaCare USA is provided as an open access plan. Enrollees can obtain treatment from any licensed dentist and do not need to select a dentist upon enrolling in the plan. Because enrollees can visit any dentist, no specialty care authorization is needed. Deductibles and maximums may apply for services provided by an out-of-network dentist.
** Non-Delta Dental, non-contracted dentists (out-of-network dentists) are paid based on usual and customary charges; therefore, you may pay higher out-of-pocket costs when using a non-network dentist.
*** Missing Tooth Limitation – Replacement of a missing tooth is covered under Class III benefits, however a 24-month coverage limitation exists. For replacement of a missing tooth within 24 months of enrollment, the plan pays at 30%, and you will pay 70%. For 25 months and beyond, the plan pays at 60%, and you will pay 40%.
† If a DeltaCare USA provider determines that a patient requires services from a specialist and there is no DeltaCare USA specialist within the lesser of 35 miles or one hour commuting time, the patient will be authorized to seek treatment from a PPO, Premier or non-network specialist.
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