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DeltaCare USA
®
Dental Health Care Program for
Eligible Employees and Dependents
Combined Evidence of Coverage and Disclosure Form
California State Employees
Provided by:
Delta Dental of California
17871 Park Plaza Drive, Suite 200
Cerritos, CA 90703
Administered by:
Delta Dental Insurance Company
P.O. Box 1803
Alpharetta, GA 30023
800-422-4234
deltadentalins.com
CAEOC-R11
V14
EVIDENCE OF COVERAGE
DISCLOSURE FORM
®
DeltaCare USA Dental HMO Program
This booklet is a Combined Evidence of Coverage and Disclosure Form (“EOC”)
for your DeltaCare USA Dental HMO Program (“Program”) provided by Delta
Dental of California (“Delta Dental”). The Program has been established and is
administered in accordance with the provisions of a Group Dental Service Contract
(“Contract”) issued by Delta Dental.
THE EOC CONSTITUTES ONLY A SUMMARY OF THE PROGRAM. AS
REQUIRED BY THE CALIFORNIA HEALTH & SAFETY CODE, THIS
IS TO ADVISE YOU THAT THE CONTRACT MUST BE CONSULTED
TO DETERMINE THE EXACT TERMS AND CONDITIONS OF THE
COVERAGE PROVIDED UNDER IT.
A COPY OF THE CONTRACT WILL BE FURNISHED UPON REQUEST. ANY
DIRECT CONFLICT BETWEEN THE CONTRACT AND THE EOC WILL BE
RESOLVED ACCORDING TO THE TERMS WHICH ARE MOST FAVORABLE
TO YOU. READ THIS EOC CAREFULLY AND COMPLETELY. PERSONS
WITH SPECIAL HEALTHCARE NEEDS SHOULD READ THE SECTION
ENTITLED “SPECIAL NEEDS”.
A STATEMENT DESCRIBING DELTA DENTAL’S POLICIES AND
PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL
RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON
REQUEST.
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW
HOW TO OBTAIN DENTAL BENEFITS.
IMPORTANT: If you opt to receive dental services that are not covered services
under this plan, a Contract Dentist may charge you his or her usual and customary
rate for those services. Prior to providing a patient with dental services that are not
includes each anticipated service to be provided and the estimated cost of each
service. If you would like more information about dental coverage options, you may
call Customer Service at 800-422-4234 or your insurance broker. To fully understand
your coverage, you may wish to carefully review this evidence of coverage
document.
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#01* 203
SCHEDULE A
Description of Benefits and Copayments
-
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Schedule B
$$
Enrollees should discuss all
treatment options with their Contract Dentist prior to services being rendered.
Text that appears in italics below is specifically intended to clarify the delivery
of benefits under the DeltaCare USA program and is not to be interpreted
as CDT-2014 procedure codes, descriptors or nomenclature that are under
copyright by the American Dental Association. The American Dental
Association may periodically change CDT codes or definitions. Such updated
codes, descriptors and nomenclature may be used to describe these covered
procedures in compliance with federal legislation.
CODE
DESCRIPTION
PAYS
10<1 &$+
&
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10B1
+&
+
&
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10J1 "$
...................................................
10J0 #
.................................................
1<01 6
$
&$limited to 1
series every 24 months ..................................................
1<<1 6
$
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1<A1 6
$$&&
&$up to and
including 13 films ........................................................
1<31 6
$$&$ ...............................
1<C1 )
&$ ...................................
1<?1 )
$&&
&$ ......................
1<D1 &$ .................................
1<D< &$ .................................
1<DA &$ ..................................
0?
% % % % % % % % % % % %
%
%
%
%
%
%
#01* 203
1<D3 &$limited to 1 series every 6
months ..................................................................... % 1<DD 2
$
D
B&$ ..................... % 1AA1 $&$ ......................................... % 1AC1 *$
$
&
)
............................................................................... % 13?1 +
......................................................... % 1JJJ !$&&
$$&'
includes office visit,
per visit (in addition to other services) ............................... % 0001 )cleaning&
2 per 12 month period ...............
00<1 )cleaning$&2 per 12 month period ...............
0<1? -$$
&+child to age 18 ...........
0<1B -$$
&child to age 18 .....................
0A01 %
$$
&
& .................
0A<1 -$$$
$
&+
&
0AA1 *
$
...............................................
0AC0 "
to age 18 only ...................................
0AC< +
+
&
$4
to age 18 only ...........................
0C01 "$
)&
..................................
0C0C "$
)&
....................................
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+
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+
.............................
%
%
%
%
%
%
%
%
%
%
%
%
%
- Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases,
liners and acid etch procedures.
Replacement of crowns and onlays requires the existing restoration to be 5+ years
old.
<031 #$'
...................... % <0C1 #
$'
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$'
................... % <0?0 #$'
.......... % <AA1 *$ ................................................ % <AA0 ,&$
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/ .................................................. % <AJ1 ,&$
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#01* 203
<AJ3
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<C3A
<C33
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<D0<
<D<1
<D<0
<D<<
<D31
<DC1
<DC0
<DC<
<DB1
<DB0
<DB<
<DJ1
<DJ0
<DJ<
<DJ3
<J01
<J0C
<J<1
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<J30
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canal preparation ........................................................
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includes
canal preparation ........................................................
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&
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$base metal post;
includes canal preparation .............................................
$&&
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base metal post;
includes canal preparation .............................................
-$.$
&
/palliative treatment only .....
,
$
$to age 18
only .........................................................................
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*
IC111
IC111
IC111
% % IC111
% IC111
% IC111
IC111
IC111
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% % % % % % % % % % I3111
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I<111
I<111
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IC111
IC111
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% % #01* 203
"" Includes preoperative and postoperative evaluations and treatment under a local
anesthetic.
3<01 7+$
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limited to 5 quadrants during any 12 consecutive
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limited to 5 quadrants during any 12 consecutive
months ..................................................................... % 3ACC &&
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...................................... % ##$ %
&'()*
Replacement of a denture or a partial denture requires the existing denture to be
5+ years old.
Rebases and relines are limited to 1 per denture during any 12 consecutive months.
C001
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C001
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)denture duplication ................
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#01* 203
C301
C300
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.)/replace extracted anterior
teeth for adults during healing and as anterior space maintainers
for children ...............................................................
CB<0 6
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.&/replace extracted anterior
teeth for adults during healing and as anterior space maintainers
for children ...............................................................
CBC1 -$&
')2 per denture ......................
CBC0 -$&
'&2 per denture ....................
% % % % % % % % % % % % I<111
I<111
I<111
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012.&34'1'.34513
31661112.5'1.6'7'1.89*
A fixed bridge is considered standard dental treatment when it is necessary to
replace a missing permanent anterior tooth in a person 16 years old or older.
Fixed bridges used to replace missing posterior teeth are considered optional
when the abutment teeth are dentally sound and would be crowned only for the
purpose of supporting a pontic. A fixed bridge used under these circumstances is
<0
#01* 203
considered optional dental treatment. Fixed bridges are not a benefit when provided
in connection with a partial denture on the same arch.
Replacement of a crown, pontic or onlay requires the existing bridge to be 5+
years old.
?<1C $&$
&$
............................... IC111
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2 ........................................ IC111
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&
............................... IC111
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2 .......................................................
IC111
2
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....................... IC111
?<30 $$&
&
............... % ?<3< $$&
2 ............................. IC111
?<C1 $
2 ................................. % ?<C0 $
&
........................ % ?<C< $
2 ....................................... % ?C3C ,
$
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............. IC111
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$ 2 ........................ IC111
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&$
&$
............................... IC111
?D<1
2 ................................ % ?D<0
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....................... % ?D<<
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......................................... % ?J31 "
4 ............................................................. % ?JB1 )&
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$
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Includes preoperative and postoperative evaluations and treatment under a local
anesthetic.
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$
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(extraction) ....... % D031 )
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$+/ ......................................................... % <<
#01* 203
D<01 "$+
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...........................................
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...........................................
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%
%
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%
I0C11
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% % % % % % % %
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% % $$ ,
%
The listed copayment for orthodontic treatment covers up to 24 months of active
treatment and 24 months of retention (includes adjustments and office visits)
provided by Contract Orthodontists. The Enrollee is responsible for an office visit
charge beyond 24 months of orthodontic treatment and/or beyond 24 months of
retention.
- In the event orthodontic treatment is not required or is declined by the Enrollee,
a fee of $25.00 will apply. The Enrollee is also responsible for any incurred
orthodontic diagnostic record fees.
B1D1
+
&
$
&
child or adolescent to age 19 ........................................ I0'11111
B1B1
+
&
$
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adolescent to age 19 .....................................................I0'11111
B1J1
+
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adults, including dependent adult children to age 26 .... I0'11111
<A
#01* 203
B??1 &
$
+
not to be charged with any other
consultation procedure(s) ............................................... % BJJJ !$&
&
$$&'
includes the
START-UP FEE, which includes initial examination, diagnosis,
consultation, initial banding and the retention phase of treatment
I<C111
,=;
J001 +.$/
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J<01 ($
$:$
+$
$& .................................................................
J<00 ,$4
..............................................
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+
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J331 *$+
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- includes failed
appointment without 24 hour notice ...................................
% % % % % % % % IC11
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B113<<3<A3
Optional is defined as any alternative procedure presented by the Contract Dentist
that satisfies the same dental need as a covered procedure, is chosen by the Enrollee,
and is subject to the limitations and exclusions of the program. The applicable
charge to the Enrollee is the difference between the Contract Dentist's "filed fee"
for the Optional procedure and the "filed fee" for the covered procedure, plus any
applicable Copayment for the covered procedure. Optional treatment does not apply
when alternative choices are benefits. "Filed fees" means the Contract Dentist's fees
on file with Delta Dental. Questions regarding the DeltaCare USA program should
be directed to the Customer Service department at 800-422-4234.
**-%*-"
An amalgam is the benefit.
Base metal is the benefit. Noble or high noble metal (semi precious, precious), if
used, will be charged to the Enrollee at the actual lab cost of the high noble metal.
This charge also applies to a titanium crown.
<3
#01* 203
SCHEDULE B
Limitations of Benefits
0
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Schedule A, Description of Benefits and Copayments.
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<C
#01* 203
Exclusions of Benefits
0
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&&Schedule A'Description of
Benefits and Copayments
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<D
#01* 203
If you have any questions or need additional information,
call or write:
Toll Free
800-422-4234
Delta Dental of California
17871 Park Plaza Drive, Suite 200
Cerritos, CA 90703
IMPORTANT: Can you read this document? If not,
we can have somebody help you read it. For free
help, please call Delta Dental at 1-800-422-4234.
You may also be able to receive this document in
Spanish or Chinese.
IMPORTANTE: ¿Puede leer este documento? Si
no, podemos ayudarle. Para obtener ayuda gratis,
llame a Delta Dental al 1-800-422-4234. También
puede recibir este documento en español o chino.
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CAEOC-R11
EOC_CAD10_V14_12.02.2013