Delta Dental

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Delta Dental

  1. 1. Delta Dental of New Mexico … administering the dental plan for State of New Mexico General Services Department Risk Management Division
  2. 2. Improved Oral Health = Improved Overall Health <ul><li>“ Oral Health is Integral To Overall Health.” </li></ul><ul><li>“… studies have demonstrated an association between periodontal diseases and diabetes, cardiovascular disease, stroke, and adverse pregnancy outcomes.” </li></ul><ul><li>From the May, 2000 Surgeon General’s Report </li></ul>GSD/RMD Dental Plan
  3. 3. <ul><li>Calendar Year Deductibles: </li></ul><ul><li>Do not apply to Diagnostic & Preventive Care Services or to Orthodontic Services </li></ul><ul><li>$ 50 per enrolled person $150 aggregate per family </li></ul>GSD/RMD Dental Plan
  4. 4. GSD/RMD Dental Plan Calendar Year Maximum *: $1750 per enrolled person * A separate lifetime maximum applies to Orthodontic Services
  5. 5. GSD/RMD Dental Plan Provider Network PPO NEW MEXICO SUBSCRIBERS AND DEPENDENTS Over 760 PPO NEW MEXICO dentist locations statewide Choose any in-network dentist statewide Dentists accept PPO NEWMEXICO dentist fees (no balance billing) Pay only coinsurance and deductible (if any) for covered services On-line dentist search deltadentalnm.com Each family member may choose a different dentist
  6. 6. GSD/RMD Dental Plan Benefits Overview * The approved fees applicable to non-participating providers are less than those applicable to PPO New Mexico dentists. Because non-network providers may balance bill patients for amounts above approved fees, and because some benefit levels are lower when services are received from non-participating providers, out-of-pocket costs may be significantly higher if services are received out-of-network. Benefit In-Network Out-of-Network Diagnostic and Preventive Services Plan Pays 100% no deductible You Pay: 0% Plan Pays 100% * no deductible You Pay: Any Amount Balance Billed * <ul><li>Oral Examinations - twice in a calendar year </li></ul><ul><li>Cleanings - twice in a calendar year </li></ul><ul><li>X-rays: Full mouth -1 in 5 years / Bitewing - 2 in a calendar year </li></ul><ul><li>Fluoride Application - through age 18, twice per calendar year </li></ul><ul><li>Emergency Treatment </li></ul><ul><li>Space Maintainers - through age 18, 5 year limitation </li></ul><ul><li>Sealants - through age 15, permanent molars only, 3 year limit </li></ul>
  7. 7. GSD/RMD Dental Program Benefits Overview * The approved fees applicable to non-participating providers are less than those applicable to PPO New Mexico dentists. Because non-network providers may balance bill patients for amounts above approved fees, and because these benefit levels are lower than those applicable in-network, out-of-pocket costs may be significantly higher if services are received out-of-network. Benefit In-Network Out-of-Network Basic Services Plan Pays 80% deductible applies You Pay: 20% Plan Pays 55% * deductible applies You Pay: 45% plus Balance Billing * <ul><li>Amalgam or composite resin fillings </li></ul><ul><li>Extractions – surgical/non-surgical </li></ul><ul><li>Periodontics - non-surgical / surgical treatment of gum disease </li></ul><ul><li>Endodontics - pulp therapy and root canal filling </li></ul><ul><li>Repair of implants, dentures and bridgework </li></ul><ul><li>General Anesthesia - intravenous sedation & general anesthesia </li></ul><ul><li>Oral Surgery </li></ul><ul><li>Stainless steel crowns </li></ul>
  8. 8. GSD/RMD Dental Program Benefits Overview * The approved fees applicable to non-participating providers are less than those applicable to PPO New Mexico dentists. Because non-network providers may balance bill patients for amounts above approved fees, and because these benefit levels are lower than those applicable in-network, out-of-pocket costs may be significantly higher if services are received out-of-network. Benefit In-Network Out-of-Network Major Services Plan Pays 60%* deductible applies You Pay: 40%* Plan Pays 35% * deductible applies You Pay: 65% plus Balance Billing * <ul><li>Inlays, Onlays, Crowns and Cast Restorations – when teeth cannot be restored with amalgam or composite resin restorations </li></ul><ul><li>Prosthodontics – Bridges, partials or complete dentures </li></ul><ul><li>Implants – specified services and related prosthodontics, subject to clinical review/approval </li></ul>
  9. 9. GSD/RMD Dental Program Benefits Overview There are Limitations and Exclusions not covered in this Benefits Overview. Refer to the Dental Benefit Handbook for complete coverage information. Benefit In-Network Out-of-Network ORTHODONTIC SERVICES No deductible Children -- up to 18 th birthday Plan Pays 75% up to a $2000 lifetime maximum Adults -- age18 and over Plan Pays 60% up to a $1750 lifetime maximum
  10. 10. <ul><ul><li>Patient Disclosure – You’re entitled to it! </li></ul></ul><ul><ul><li>PPO NEW MEXICO Dentist’s Guarantee </li></ul></ul><ul><ul><li>Upon request, a pre-treatment cost range will be provided by your dentist </li></ul></ul><ul><ul><li>Pre-determination of benefits is available from Delta Dental - recommended (not required) for expensive procedures </li></ul></ul><ul><ul><li>You and your dentist agree </li></ul></ul>GSD/RMD Dental Plan Patient Disclosure
  11. 11. GSD/RMD Dental Plan <ul><ul><li>Verify eligibility </li></ul></ul><ul><ul><li>Review benefit information </li></ul></ul><ul><ul><li>Review Calendar Year Maximum and Deductible Information </li></ul></ul><ul><ul><li>Check on a specific claim </li></ul></ul><ul><ul><li>Print a personalized ID card </li></ul></ul><ul><ul><li>Review oral health information </li></ul></ul>24/7 Information Access with the Delta Dental Online Consumer Toolkit! deltadentalnm.com
  12. 12. GSD/RMD Dental Plan <ul><li>All dental plan claims and administration services provided in New Mexico </li></ul><ul><li>Trained Benefit Representatives </li></ul><ul><ul><ul><li>Available Monday – Friday 8:00am-4:30pm </li></ul></ul></ul><ul><ul><ul><li>Albuquerque 505-855-7111 </li></ul></ul></ul><ul><ul><ul><li>Toll free 1-877-395-9420 </li></ul></ul></ul><ul><ul><ul><li>Over 95% of calls answered in fewer than 45 seconds </li></ul></ul></ul>
  13. 13. GSD/RMD Dental Plan Questions?

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