Kaiser Permanente and Delta Dental Dental Program for Kaiser Permanente FEHBP Enrollees

You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan.

Kaiser Permanente and Delta Dental of Colorado recognize that good oral health is an important part of your overall health. Your enrollment in a Kaiser Permanente FEHBP option gives you and your family two ways to maintain good oral health: a preventive dental benefit administered by Delta Dental included as part of your High Option or Standard Option benefits, and a separate optional plan, which you may be eligible to purchase for an additional premium.

*This is a brief description of the features of Kaiser Foundation Health Plan Inc.’s Buy Up and Preventive Dental Care plans. Before making a final decision, please read the plan’s federal brochure. All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal (RI 73-

019) brochure.

Preventive Dental Care (Delta Dental PPOSM plus Premier)With your FEHBP medical coverage through Kaiser Permanente, you receive dental coverage for preventive services. With Delta Dental PPO plus Premier, you may visit the dentist of your choice, but you will pay nothing for covered procedures when you visit a participating Delta Dental dentist.*

Your Preventive Dental Care plan covers 100% of charges for the following procedures (refer to your preventive procedure list to view all covered services):

Delta Dental Buy Up PlanIf you would like more extensive coverage for you and your family, you may purchase separate coverage through Delta Dental’s Buy Up Plan for an additional monthly premium. Coverage includes the following types of services (refer to

your Buy Up procedure list to view all covered services):

• Fillings• Crowns• Implants• Periodontal cleanings• Extractions

• Root canals• Dentures

You MUST be enrolled in either the High or Standard Option medical plans to purchase the dental Buy Up plan.

How to EnrollNo enrollment form is necessary for the Preventive Dental Care Plan. You will be automatically signed up for that plan with your enrollment in Kaiser Permanente’s medical plan. If you wish to purchase the additional coverage, please complete the enclosed Delta Dental enrollment and payment authorization form.

Buy Up Plan Monthly CostEmployee: $19.87

Employee + 1: $39.74

Employee + family: $79.48

Rates are effective 1/1/15–12/31/15

• Oral exams• Full-mouth and bitewing X-rays

• Cleanings• Fluoride (child and adult)

How Coverage WorksYour Preventive Dental Care plan and the Buy Up plan work differently. To help you choose the right coverage for your needs, this chart provides helpful information on how your benefits work. You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan.

Preventive Dental Care Plan Buy Up Plan

Premium Cost to Patient Coverage included with your medical plan premium Monthly premium applies

Calendar-year Maximum No annual maximum for diagnostic and preventive services $1,000

Calendar-year Deductible None $50 for individual $150 for family

Covered ServicesPREVENTIVE SERVICES

Oral Exams100% covered 100% covered under Preventive

Dental Care PlanCleaningsX-rays

BASIC SERVICESFillings

Not covered under the Preventive Dental Care plan

80% covered when treated by Delta Dental PPO dentist

50% covered when treated by Delta Dental Premier or out-of-network

dentist

Simple ExtractionsEndodontics (Root Canals)Periodontics (Gum Disease Treatment)

MAJOR SERVICES (12-month waiting period for new enrollees)Implants

Not covered under the Preventive Dental Care plan 50% coveredCrowns

Dentures

This is a brief description of the features of the Kaiser Foundation Health Plan. Before making a final decision, please read the plan’s federal brochure (RI 73-019). All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure.

Contact Delta Dental of ColoradoCustomer Service

1-800-610-0201 (toll-free) customer_service@ddpco.com

Dentist Search & Eligibilitydeltadentalco.com

Claims SubmissionPO Box 173803

Denver, CO 80217-3803

Delta Dental PPOSM plus PremierWith the Delta Dental PPO plus Premier plan, you and your family may visit any licensed dentist but will receive the greatest out-of-pocket savings if you see a Delta Dental PPO dentist. Participating dentists file claims directly with Delta Dental and accept Delta Dental’s reimbursement in full. You are responsible only for your deductible and coinsurance (as determined by your plan), as well as any charges for non-covered services up to Delta Dental’s approved amount. If you choose to see an out-of-network dentist, you will incur additional out-of-pocket expenses, and you will be billed the total amount the dentist charges (called balance-billing). When you see a Delta Dental PPO or Premier® dentist, you are protected from balance-billing.

Advantages of the Delta Dental PPO plus Premier plan

• Savings: Delta Dental PPO dentists offer subscribers the greatest savings. And you will still save money if you need a service that is not covered. Non-covered services will be billed at a discounted rate if you go to a PPO dentist.

• Choice: If you choose to visit a Premier dentist, you will still save money because Premier dentists also accept discounted fees (however, discounts are not as great as if you see a PPO dentist).

• Network: Delta Dental’s dual network has nearly 90,000 PPO providers and 145,000 Premier providers nationwide.

To find a participating dentist or to see if your current dentist is in the network, visit deltadentalco.com and click on the Find a Dentist search tool. You can also contact our customer relations department, Monday–Friday 8 a.m. to 6 p.m. MT, at 1-800-610-0201 (toll-free) or customer_service@ddpco.com.

Looking for a dentist? Concerned about costs?PPO dentists offer you the greatest savings.

Service: Porcelain Crown (Benefit illustration only. Example assumes deductible has been met.)

Greatest Patient Savings Least Patient Savings

Protected from balance-billing Not protected from balance-billing

Network Delta Dental PPO Dentist

Delta Dental Premier Dentist

Out-of-Network Dentist

Procedure Cost $1,000 $1,000 $1,000

Maximum Dentist Can Charge Patient $710 $950 Unlimited

Maximum Dentist Can Charge Insurance (MPA)* $710 $950 $660

Benefit Percentage 50% 50% 50%

Delta Dental Pays $355 $475 $330

You Pay $355 $475 $670

*The maximum a dentist can charge your insurance company is called the Maximum Plan Allowance (MPA). The MPA for an out-of-network dentist is always lower than in-network MPA. Delta Dental pays a portion of the MPA only, which exposes you to balance-billing from an out-of-network dentist.

2015 Preventive Dental Care Plan Procedure List

Any service not listed is the responsibility of the patient. Payment is based on the Maximum Plan Allowance for each type of provider.

FEHBPProcLst_2015

 

 

   

DIAGNOSTIC/PREVENTIVE SERVICES DDCO Pays Diagnostic Services PPO Premier and

Non-participating

D0120 Periodic oral evaluation 100% 100%

D0140 Limited oral evaluation — problem focused 100% 100%

D0150 Comprehensive oral evaluation 100% 100%

D0160 Detailed and extensive oral evaluation — problem focused 100% 100%

D0180 Comprehensive periodontal evaluation 100% 100%

D0210 Intraoral — complete series of radiographic images 100% 100%

D0220 Intraoral — periapical — 1st radiographic image 100% 100%

D0230 Intraoral — periapical — each additional radiographic image 100% 100%

D0240 Intraoral — occlusal radiographic image 100% 100%

D0270 Bitewing — single radiographic image 100% 100%

D0272 Bitewings — 2 radiographic images 100% 100%

D0274 Bitewings — 4 radiographic images 100% 100%

D0277 Vertical bitewings — 7 to 8 radiographic images 100% 100%

D0330 Panoramic radiographic image 100% 100%

D0340 Cephalometric radiographic image 100% 100%

D0460 Pulp vitality tests 100% 100%

Preventive Services

D1110 Prophylaxis — adult 100% 100%

D1120 Prophylaxis — child age 0–14 100% 100%

D1206 Topical application of fluoride varnish 100% 100%

D1208 Topical application of fluoride 100% 100%

D1351 Sealant — per tooth to age 15 100% 100%

D1510 Space maintainer — fixed unilateral 100% 100%

D1515 Space maintainer — fixed bilateral 100% 100%

Adjunctive Services

D9110 Palliative (emergency) treatment of pain — minor procedures 100% 100%

D9310 Consultation — diagnostic service provided by a dentist or physician other than requesting dentist or physician

100% 100%

2015 Buy Up Dental Care Plan Procedure List

Any service not listed is the responsibility of the patient. Payment is based on the Maximum Plan Allowance for each type of provider.

FEHBPProcLst_2015

 

 

 

BASIC SERVICES DDCO Pays Minor Restorative Services PPO Premier and

Non-participating

D2140 Amalgam — 1 surface, primary or permanent 80% 50%

D2150 Amalgam — 2 surfaces, primary or permanent 80% 50%

D2160 Amalgam — 3 surfaces, primary or permanent 80% 50%

D2161 Amalgam — 4 or more surfaces, primary or permanent 80% 50%

D2330 Resin-based composite — 1 surface, anterior 80% 50%

D2331 Resin-based composite — 2 surfaces, anterior 80% 50%

D2332 Resin-based composite — 3 surfaces, anterior 80% 50%

D2335 Resin-based composite — 4 or more surfaces or involving incisal angle

80% 50%

D2391 Resin-based composite — 1 surface, posterior 80% 50%

D2392 Resin-based composite — 2 surfaces, posterior 80% 50%

D2393 Resin-based composite — 3 surfaces, posterior 80% 50%

D2394 Resin-based composite — 4 or more surfaces, posterior 80% 50%

Oral Surgery    

D7140 Extraction — erupted tooth or exposed root 80% 50%

D7210 Surgical removal of erupted tooth 80% 50%

D7220 Removal of impacted tooth — soft tissue 80% 50%

D7230 Removal of impacted tooth — partially bony 80% 50%

D7240 Removal of impacted tooth — completely bony 80% 50%

D7241 Removal of impacted tooth — completely bony with unusual surgical complications

80% 50%

D7250 Surgical removal of residual tooth roots (cutting procedure) 80% 50%

Endodontics    

D3220 Therapeutic pulpotomy—primary tooth, excluding final restoration 80% 50%

D3310 Root canal therapy — anterior (excluding final restoration) 80% 50%

D3320 Root canal therapy — bicuspid (excluding final restoration) 80% 50%

D3330 Root canal therapy — molar (excluding final restoration) 80% 50%

D3346 Retreatment of previous root canal therapy — anterior 80% 50%

D3347 Retreatment of previous root canal therapy — bicuspid 80% 50%

D3348 Retreatment of previous root canal therapy — molar 80% 50%

D3410 Apicoectomy — anterior 80% 50%    

2015 Buy Up Dental Care Plan Procedure List

Any service not listed is the responsibility of the patient. Payment is based on the Maximum Plan Allowance for each type of provider.

FEHBPProcLst_2015

 

 

BASIC SERVICES (CONTINUED) DDCO Pays

PPO Premier and Non-participating

D3421 Apicoectomy — bicuspid 80% 50%

D3425 Apicoectomy — molar (first root) 80% 50%

Periodontics

D4210 Gingivectomy or gingivoplasty — per quadrant 80% 50%

D4211 Gingivectomy or gingivoplasty — 1–3 teeth per quadrant 80% 50%

D4240 Gingival flap procedure, including root planing per quadrant 80% 50%

D4241 Gingival flap procedure, including root planing — 1–3 teeth per quadrant

80% 50%

D4260 Osseous surgery — per quadrant (including flap entry and closures)

80% 50%

D4261 Osseous surgery — 1–3 teeth per quadrant (including flap entry and closures)

80% 50%

D4263 Bone replacement graft — first site in quadrant 80% 50%

D4264 Bone replacement graft — each additional site in quadrant 80% 50%

D4341 Periodontal scaling and root planing — per quadrant 80% 50%

D4342 Periodontal scaling and root planing — 1–3 teeth per quadrant 80% 50%

D4910 Periodontal maintenance procedures following active therapy (periodontal prophylaxis)

80% 50%

MAJOR SERVICES DDCO Pays PPO Premier and

Non-participating

D2740 Crown — porcelain/ceramic substrate 50% 50%

D2750 Crown — porcelain fused to high noble metal 50% 50%

D2751 Crown — porcelain fused to predominantly base metal 50% 50%

D2752 Crown — porcelain fused to noble metal 50% 50%

D2780 Crown — 3/4 cast high noble metal 50% 50%

D2781 Crown — 3/4 cast predominantly base metal 50% 50%

D2782 Crown — 3/4 cast noble metal 50% 50%

D2790 Crown — full cast high noble metal 50% 50%

D2791 Crown — full cast predominantly base metal 50% 50%

D2792 Crown — full cast noble metal 50% 50%

D2920 Recement crown 50% 50%

2015 Buy Up Dental Care Plan Procedure List

Any service not listed is the responsibility of the patient. Payment is based on the Maximum Plan Allowance for each type of provider.

FEHBPProcLst_2015

 

 

MAJOR RESTORATIVE SERVICES (CONTINUED) DDCO Pays PPO Premier and

Non-participating

D2930 Prefabricated stainless steel crown — primary tooth 50% 50%

D2940 Protective restoration 50% 50%

D2950 Core buildup, including any pins when required 50% 50%

D2951 Pin retention — per tooth, in addition to restoration 50% 50%

D2952 Post and core in addition to crown, indirectly fabricated 50% 50%

D2953 Each additional indirectly fabricated post — same tooth 50% 50%

D2954 Prefabricated post and core in addition to crown 50% 50%

D2957 Each additional prefabricated post — same tooth 50% 50%

Implant Surgical Services

D3460 Endodontic endosseous implant 50% 50%

D6010 Surgical placement of implant body: endosteal implant 50% 50%

D6013 Surgical placement of mini implant 50% 50%

D6040 Surgical placement: eposteal implant

50% 50%

D6050 Surgical placement: transosteal implant 50% 50%

D6052 Semi-precision attachment abutment 50% 50%

D6055 Connecting bar — implant supported or abutment supported 50% 50%

D6056 Prefabricated abutment — includes modification and placement 50% 50%

D6057 Custom fabricated abutment — includes placement 50% 50%

D6100 Implant removal, by report 50% 50%

Implant Restorative Services

D6053 Implant/abutment supported removable denture for completely edentulous arch

50% 50%

D6054 Implant/abutment supported removable denture for partially edentulous arch

50% 50%

D6058 Abutment supported porcelain/ceramic crown 50% 50%

D6059 Abutment supported porcelain fused to metal crown (high noble metal)

50% 50%

D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)

50% 50%

 

 

2015 Buy Up Dental Care Plan Procedure List

Any service not listed is the responsibility of the patient. Payment is based on the Maximum Plan Allowance for each type of provider.

FEHBPProcLst_2015

 

 

MAJOR RESTORATIVE SERVICES (CONTINUED) DDCO Pays

PPO Premier and Non-participating

D6061 Abutment supported porcelain fused to metal crown (noble metal) 50% 50%

D6062 Abutment supported cast metal crown (high noble metal) 50% 50%

D6063 Abutment supported cast metal crown (predominantly base metal) 50% 50%

D6064 Abutment supported cast metal crown (noble metal) 50% 50%

D6065 Implant supported porcelain/ceramic crown 50% 50%

D6066 Implant supported porcelain fused to metal crown (titanium, titanium allow, high noble metal)

50% 50%

D6067 Implant supported metal crown (titanium, titanium allow, high noble metal)

50% 50%

D6068 Abutment supported retainer for porcelain/ceramic FPD 50% 50%

D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)

50% 50%

D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)

50% 50%

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)

50% 50%

D6072 Abutment supported retainer for cast metal FPD (high noble metal)

50% 50%

D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)

50% 50%

D6074 Abutment supported retainer for cast metal FPD (noble metal) 50% 50%

D6075 Implant supported retainer for ceramic FPD 50% 50%

D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)

50% 50%

D6077 Implant supported retainer for cast metal FPD (titanium, titanium allow, or high noble metal)

50% 50%

D6078 Implant/abutment supported fixed denture for completely edentulous arch

50% 50%

D6079 Implant/abutment supported fixed denture for partially edentulous arch

50% 50%

D6094 Abutment supported crown (titanium) 50% 50%

D6194 Abutment supported retainer crown for FPD (titanium) 50% 50%    

2015 Buy Up Dental Care Plan Procedure List

Any service not listed is the responsibility of the patient. Payment is based on the Maximum Plan Allowance for each type of provider.

FEHBPProcLst_2015

 

 

MAJOR SERVICES (CONTINUED) DDCO Pays Other Implant Related Services PPO Premier and

Non-participating

D5875 Modification of removable prosthesis following implant surgery 50% 50%

D6090 Repair implant supported prosthesis, by report 50% 50%

D6092 Recement implant/abutment supported crown 50% 50%

D6093 Recement implant/abutment supported fixed partial denture 50% 50%

D6095 Repair implant abutment, by report 50% 50%

D6190 Radiographic/surgical implant index, by report 50% 50%

Fixed Prosthetics

D6210 Pontic — cast high noble metal 50% 50%

D6211 Pontic — cast predominantly base metal 50% 50%

D6212 Pontic — cast noble metal 50% 50%

D6240 Pontic — porcelain fused to high noble metal 50% 50%

D6241 Pontic — porcelain fused to predominantly base metal 50% 50%

D6242 Pontic — porcelain fused to noble metal 50% 50%

D6750 Crown — porcelain fused to high noble metal 50% 50%

D6751 Crown — porcelain fused to predominantly base metal 50% 50%

D6752 Crown — porcelain fused to noble metal 50% 50%

D6790 Crown — full cast high noble metal 50% 50%

D6791 Crown — full cast predominantly base metal 50% 50%

D6792 Crown — full cast noble metal 50% 50%

Removable Prosthetics

D5110 Complete denture — upper 50% 50%

D5120 Complete denture — lower 50% 50%

D5130 Immediate denture — upper 50% 50%

D5140 Immediate denture — lower 50% 50%

D5213 Upper partial denture-metal base with resin saddles (including any conventional clasps, rests and teeth)

50% 50%

D5214 Lower partial denture — metal base with resin saddles (including any conventional clasps, rests and teeth)

50% 50%

   

2015 Buy Up Dental Care Plan Procedure List

Any service not listed is the responsibility of the patient. Payment is based on the Maximum Plan Allowance for each type of provider.

FEHBPProcLst_2015

 

 

MAJOR SERVICES (CONTINUED) DDCO Pays PPO Premier and

Non-participating

D5510 Repair broken complete denture base 50% 50%

D5520 Replace missing/broken teeth-complete denture (each tooth) 50% 50%

D5630 Repair/replace broken clasp partial denture 50% 50%

D5640 Replace tooth on partial denture per tooth 50% 50%

D5650 Add tooth to existing partial denture 50% 50%

D5660 Add clasp to existing partial denture 50% 50%

D5750 Reline complete upper denture (laboratory) 50% 50%

D5751 Reline complete lower denture (laboratory) 50% 50%  

Today’s Date:

Enrollment Form & Payment AuthorizationKaiser Permanente FEHBP Enrollees

Subscriber Information(complete for all enrollments/changes/updates)

Subscriber Name (Last) (First) (Middle Initial)

Subscriber Social Security Number Subscriber Date of Birth (MM-DD-YYYY)

Mailing Address

City State Zip Code

☐ Employee Only

☐ Female

Subscriber Phone Number (including area code) Subscriber Email Address

Select Coverage: ☐ Employee and Family

Please list all dependents. All fields are required.

Add Delete Last Name First Name SSN Date of Birth M F☐ ☐ ☐ ☐☐ ☐ ☐ ☐☐ ☐ ☐ ☐☐ ☐ ☐ ☐☐ ☐ ☐ ☐

☐ Male

Plan Enrollment

To enroll, complete this form, including premium payment information and authorization. Return the completed form to: Delta Dental of Colorado, PO Box 5468, Denver, CO 80217-5468. Or fax it to: 303-741-9160.

Requested Effective Date (Must be first of the month) KP_FEHBP_EnrollForm_072214

Automatic Premium Payment (APP) Authorization

Your payment will be automatically deducted from your bank account on the 27th of each month. Complete this form and be sure to sign it before you submit it. If this form is received by the 20th, your plan effective date will be the first of the month following receipt.

Name on Account

Name of Bank

Routing Number (first nine digits on check) Account Number

☐ Savings

☐ Checking

Account Type:

Automatic Premium Payment (APP) Agreement

I hereby authorize Delta Dental of Colorado or its agent to initiate debit entries to my checking or savings account as indicated. I acknowledge that payment for the upcoming period will be deducted from my account on the 27th of the previous month (initial payment will be deducted upon receipt of enrollment form). If the charge is declined for any reason, Delta Dental will attempt to charge me again on the 27th of the following month. If the charge is still declined, they will immediately terminate my contract for nonpayment of premium, effective as of the last day of the grace period.

This authorization is to remain in full force and effect until Delta Dental of Colorado or its agent receives thirty (30) days notice from me of its cancellation. The notification must be sent to Delta Dental of Colorado, PO Box 5468, Denver, CO 80217-5468.

Signature of Authorized Account Holder