Small Group · see any dentist, but claims will be paid according to the PPO schedule; therefore, it is in their best financial interest to visit a PPO dentist. Cost-conscious members

Small Group Made Simple

Delta Dental of Colorado

Dental Plans for Small Groups (1-100)

This manual is your one-stop shop for quoting and enrolling small groups from 1-100 lives. It’s simple! In this guide, you will find everything you need to enroll a small group with Delta Dental of Colorado.

Using Easy Quote—Quoting and enrolling small groups ......................................................................................Page 3

Small Group Made Simple General Product Descriptions ..................................................................................... Page 4

Small Group Made Simple Plan Grid ...................................................................................................................... Page 5

Exclusions and Limitations ........................................................................................................................................Page 6-7

Underwriting Guidelines ...........................................................................................................................................Page 8

Plan 1C Benefit Summary Sheet ...............................................................................................................................PDF Attachment 1

Plan 1V Benefit Summary Sheet ...............................................................................................................................PDF Attachment 2

Plan 2C Benefit Summary Sheet ...............................................................................................................................PDF Attachment 3

Plan 2V Benefit Summary Sheet ...............................................................................................................................PDF Attachment 4

Plan 3 Benefit Summary Sheet ..................................................................................................................................PDF Attachment 5

Plan 4 benefit Summary Sheet ..................................................................................................................................PDF Attachment 6

Plan 5 Benefit Summary Sheet ..................................................................................................................................PDF Attachment 7

Plan 6 Benefit Summary Sheet .................................................................................................................................PDF Attachment 8

2


Prio• r carrier bill/benefit booklet (voluntary and 1-4 groups only)Copy of the sold original quote•One month’s premium•Federal wage and tax, Schedule C (1-4 groups only)•

You may also submit your completed forms via e-mail, to [email protected].

Using Easy Quote

3


It’s easy to quote small groups from 1-100 enrolled employees with a few clicks of your mouse. All you need is the group name, effective date, zip code, industry code and the number of employees enrolling in the plan. You will receive a competitive quote that you can print or e-mail immediately.

Quote a Small Group

1. Log in to Broker Connection and click on the Broker Menu link.

2. Click on the Easy Quote link.

3. Enter the required group information on the Getting Started page. Click Continue.

4. Select from the drop down menu the product you would like to quote. You may run up to three quotes at a time. Select specific options based on the product. Rates will appear once you have made a selection for all options.

5. Adjust your quote (by changing products/options) until you are satisfied. For any quotes that you would like to save, click the “Add to rate quote” link at the bottom of the page. When finished, click “Save and Continue.”

6. You may now view or e-mail your quote, or create a new quote.

7. View your saved quotes from the past 12 months through the main Broker Connection page - just look for the “Saved Quotes” link. Use the action links on the right side of the screen to view, e-mail, update or delete a quote.

Enroll a Small Group

Please submit the following to enroll a group:Grou• p applicationGroup Health Plan Certification•Enrollment forms•ACH Authorization form (optional 10-100)•Employer Connection Authorization form•

Send completed forms and binder check to:

Delta Dental of Colorado ATTN: Small Group Sales4582 S. Ulster Street, Suite 800Denver, CO 80237

Phone: 303-741-9300 ext. 3300

What’s Next

If the completed application, enrollment forms and binder check are received before the 20th of the month, the group will be eligible on the first of the following month. Delta Dental will send the group a welcome letter once the application and enrollment forms have been processed. Please Note: Enrollment forms must be completed for all eligible employees enrolling in the plan at initial time of enrollment.

Product DescriptionsGroups of all sizes need options for dental benefits. Now Delta Dental of Colorado offers plans specific to your small groups—those with one to 100 employees. Our Small Group Made Simple plans offer options that focus on affordability, choice and network, and include an option for a non-insurance discount plan. Descriptions of each type of plan are listed blow. See page 5 for plan designs and details.

Delta Dental PPOSM plus Premier

Subscribers may visit any licensed dentist, but will enjoy the greatest out-of-pocket savings when they see a Delta Dental PPO dentist. Participating dentists file claims directly with Delta Dental and accept Delta Dental’s reimbursement in full. Subscribers are responsible only for their deductible and coinsurance, as well as any charges for non-covered services up to Delta Dental’s approved amount. Subscribers who see a non-participating dentist will incur additional out-of-pocket expenses and will be balance-billed. Your clients are protected from balance-billing when they see a PPO or Premier dentist.

Advantages of the Delta Dental PPO plus Premier plans:

Savings• —Delta Dental PPO dentists offer subscribers the greatest savings. And, non-covered services will be billed at a discounted rate if your client goes to a PPO dentist.

Choice• —If your client elects to visit a Premier dentist he or she will still see savings, because Premier dentists also accept discounted fees (however, discounts are greatest with a PPO dentist).

Network• —The PPO network provides your clients access to 0ver 1,500 Delta Dental PPO providers in Colorado. The dual network (which includes Premier dentists) includes nearly 9 out of 10 dentists in Colorado.

Maximum Allowable Charge (MAC) a feature of Delta Dental PPO

The Maximum Allowable Charge is a feature of Delta Dental PPO that will help subscribers save on out-of-pocket costs. Your clients may see any dentist, but claims will be paid according to the PPO schedule; therefore, it is in their best financial interest to visit a PPO dentist. Cost-conscious members should keep this in mind when choosing a dentist.

Members who see a PPO dentist receive the following benefits with a MAC plan:Access • to 1,500 PPO dentists in Colorado Lower out-of-pocket costs due to Delta Dental’s provider agreement with network dentists•No claim forms • to completeNo balance-billing•

Delta Dental Premier®

With a Delta Dental Premier plan, your clients may visit any licensed dentist, but will enjoy the most savings if they see a Delta Dental Premier dentist. Premier dentists file claims directly with Delta Dental and accept Delta Dental reimbursement in full. Delta Dental Premier is our largest provider network and includes more than 2,800 dentists in Colorado. Available only in certain zip codes.

Delta Dental Patient Direct®

Delta Dental Patient Direct is a dental discount plan for groups. It is not an insurance plan Patient Direct provides members significant savings1 on certain dental procedures. With Patient Direct, your clients have no maximums, no waiting periods, no annual deductible and no claims to file. Patient Direct is a great option for groups who want to offer their members savings toward dental care, but who cannot afford to provide traditional dental benefits

1 Savings shown on marketing materials are an approximation and could be higher or lower depending on where the network dentist is located in Colorado and if they are a general dentist or a specialist.

4


Plan NameCalendar Year

Deductible

(Individual/Family)

Benefits Paid

PPO Dentist Premier Dentist Non-Participating Dentist

Plan 1 MAC PPO

$50 / $150 100 / 80 / 50 90 / 80 /50 90 / 80 / 50

Plan 2 MAC PPO

$25 / $75 100 / 100 / 50 80 / 80 / 50 80 / 80 / 50

Plan 3 PPO plus Premier

$50 / $150 100 / 80 / 50 80 / 80 / 50 80 / 80 / 50

Plan 4 Passive PPO plus Premier

$50 / $150 100 / 80 / 50 100 / 80 / 50 100 / 80 / 50

Plan 5 PPO plus Premier

$50 / $150 100 / 90 / 60 100 / 80 / 50 100 / 80 / 50

Plan 6 Premier

$50 / $150 100 / 80 / 50 100 / 80 / 50 100 / 80 / 50

Plan 7 Patient Direct

Discount Plan Discount Plan Discount Plan Discount Plan

Calendar Year Maximum*: • Plans have a choice of one general maximum: $1,000; $1,500 or $2,000.

Prevention First: • All Plans have Prevention First—Diagnostic & Preventive does not count against calendar year maximum when patient sees a PPO provider (Premier provider for Plan 6 only).

Orthodontics: • Optional. When selected, coverage is 50% coinsurance for dependents to age 19; $1,000 lifetime maximum. Only available for groups of 25 or more enrolled employees.

Groups of 1-4 Lives: • Plan 1 is available for small groups with 1-4 enrolled employees. Waiting periods apply.

Voluntary Options: • Plans 1, 2 and 7 are available as a voluntary option for groups of 5-100 lives. Voluntary limitations and exclusions apply. Waiting periods apply. Plans have open enrollment - members can add coverage once per year.

Dual Choice: • Groups of 51+ enrolled employees may select Plan 1 - 6 to be offered with Patient Direct.

Plans 1-2: If the patient’s dentist charges more than the PPO dentist’s Allowable Fee, the patient will be responsible for the excess charges. If the patient sees a Premier dentist, he or she will be responsible for the difference between the PPO dentist’s Allowable Fee and the fee from the Premier Maximum Plan Allowance (MPA). If the patient sees a non-participating dentist, he or she will be responsible for the difference between the PPO dentist’s Allowable Fee and the full billed charges.

Plans 3, 4 & 5: PPO Dentist—Benefits paid based on the PPO dentist’s allowable fee, or the actual fee charged, whichever is less. Premier Dentist—Payment is based on the Premier Maximum Plan Allowance (MPA), or the fee actually charged, whichever is less. Non-Participating Dentist—Payment is based on the non-participating Maximum Plan Allowance. Member is responsible for the difference between the non-participating MPA and the full fee charged.

Plan 6: Only available in certain zip codes. Premier Dentist - Payment is based on the Premier Maximum Plan Allowance (MPA), or the fee actually charged, whichever is less. Non-Participating Dentist - Payment is based on the non-participating Maximum Plan Allowance. Member is responsible for the difference between the non-participating MPA and the full fee charged.

*Plan 7: Patient Direct is a discount plan, not insurance. Calendar Year Maximum does not apply. Patient must see a Patient Direct provider for discounts.

Quote small groups quickly at www.deltadentalco.com.5

Small Group Made Simple Plan Options

DIAGNOSTIC & PREVENTIVE BENEFITS Limitations on Diagnostic, Preventive and Adjunctive Benefits:

Oa) ral examinations are covered once in any 6-month period. Cleanings and/or any procedure that includes a component of cleaning, are covered once in any 6-month period. For individuals with certain medical b) conditions (as shown in the Employee Benefit Booklet), 2 additional cleanings (or any procedure that includes a component of cleaning) will be provided during a 12-month period. Topical fluoride application is covered through age 15 and only twice in 12 months. c) Full mouth x-rays are covered once every 60 months under any Delta Dental plan unless documentation of special need is provided. Individual bitewing d) x-rays are covered once every 12 months while the patient is under any Delta Dental plan. A panoramic survey (which may include bitewing x-rays and/or periapical x-rays) is considered a full mouth x-ray. Total allowance for individual periapical x-rays, intraoral occlusal x-rays, extraoral x-rays and/or bitewing x-rays performed on the same day will not exceed the allowance for full mouth x-rays.Space maintainers are covered for premature loss of primary back teeth through age 13. e) Sealants are covered once per tooth in any 36 consecutive month period for permanent first and second molars for children through age 14.f)

BASIC BENEFITSLimitations on Basic Benefits:

Ta) he same basic restorative service is covered once in any 24-month period for the same tooth.Composite fillings are covered on front teeth; amalgams on back teeth.b) Surgical periodontal services are covered once in any 36-month period for the same quadrant, tooth or site; non-surgical services are covered once in any 24-c) month period for the same quadrant.Pulpotomy/pulpectomy is covered only for primary teeth.d) A course of treatment for apexification/recalcification (initial, interim, and final visits) is covered once per tooth.e)

MAJOR BENEFITSLimitations on Major Benefits - Special Restorative:

Special restorative services (ca) rowns, onlays and buildups) are covered once in any 84-month period per tooth.Any laboratory processed special restorative service or other special restorative service (except preformed shell crowns) is not covered for children under 16.b) Restorations on molar teeth will be limited to the allowance for a full metal restoration. c)

Limitations on Major Benefits - ProsthodonticFixed pra) osthodontic services are covered once in any 84-month period per tooth; removable prosthodontic appliances are covered once in any 60-month period to replace the same missing teeth. Prosthodontic services are a benefit only to replace teeth extracted while covered. Fixed bridges (fixed partial dentures) and/or cast metal framework partial dentures (removable partial dentures) are not covered for persons under age 16.b) Fixed and removable prosthodontic appliances are not covered in the same arch. Allowance will be limited to the allowance for a removable appliance. c) Exception will be made when the fixed bridge (fixed partial denture) replaces front teeth.Reline or rebase of a prosthodontic appliance will be covered only once in any 36-month period. d)

ORTHODONTIC BENEFITS (ONLY if selected)Limitations on Orthodontic Benefits:

No a) benefits will be provided for:Replacement or repair of appliances.•Orthodontic care provided in the treatment of periodontal cases or cases involving treatment or repositioning of the temporomandibular joint.•

Periodic orthodontic payments will end upon termination of treatment for any reason prior to completion of the case, or upon termination of eligibility.b) For an orthodontic treatment plan started prior to the eligibility date of the patient, Delta Dental will begin periodic payments with the first payment due c) following the patient eligibility date. The maximum benefit will be determined based upon the prior payment history.

EXCLUSIONSThe following services are not benefits:

Sea) rvices for treatment of congenital (present at birth) or developmental (following birth) malformations, except intraoral dental services for treatment of a condition which is related to or developed as a result of cleft lip and/or cleft palate, unless otherwise included as a covered service.Services for cosmetic reasons.b) Services for restoring tooth structure lost from wear, erosion, attrition, abrasion, or abfraction.c) Services related to protecting, altering, correcting, stabilizing, rebuilding or maintaining teeth due to improper alignment, occlusion or contour.d) Services related to periodontal stabilization of teeth.e) Habit appliances, night guards, occlusal guards, athletic mouth guards and gnathological (jaw function) services, bite registration or analysis, or any f) related services.Pre-medication, analgesia, hypnosis or any other patient management services (except covered anesthetic services).g) Charges for prescription drugs.h) Any experimental or investigational procedures.i) Hospital costs and any additional fees charged by the dentist or hospital for hospital services or visits, or charges for use of any facility.j) Any anesthesia service not specifically included in covered services. k) Intraoral grafts when done in areas where a tooth/teeth are not present.l) Extraoral grafts (grafting of tissues or other substances from outside the mouth to or into oral tissues), augmentations or implants and/or any associated m) appliances. Removal of implants or any associated services.Myofunctional therapy or speech therapy.n) Services for the treatment of any disturbances of the temporomandibular joint (TMJ), facial pain, or any related conditions.o) Oral hygiene instructions or dietary instructions. Preventive control programs, including home care items.p) Completion of forms, providing diagnostic information or records, or duplication of x-rays or other records. Missed appointment charges.q) Replacement of lost, stolen or damaged appliances.r) Bone grafting when done in the same site as a tooth extraction, implant, apicoectomy or hemisection.s) Implant placement and implant restorative procedures.t)

This form provides a brief description of limitations and exclusions. The Employee Benefit Booklet provides a more complete explanation of coverage, including limitations and exclusions.

Limitations & Exclusions Voluntary Groups of 5 - 100 Enrolled Employees

All Groups of 1 - 4 Enrolled Employees

BOT_L&E_V5-50_101410

DIAGNOSTIC & PREVENTIVE BENEFITS Limitations on Diagnostic, Preventive and Adjunctive Benefits:

Oa) ral examinations are covered twice in any 12-month period. Cleanings are covered twice in any 12-month period. For individuals with history of prior definitive periodontal treatment, or certain medical conditions (as b) shown in the Employee Benefit Booklet), 2 additional cleanings will be provided during a 12 month period. Topical fluoride application is covered through age 15 and twice in 12 months. c) Full mouth x-rays are covered once every 60 months under any Delta Dental plan unless documentation of special need is provided. Individual bitewing d) x-rays are covered once every 12 months while the patient is under any Delta Dental plan. A panoramic survey (which may include bitewing x-rays and/or periapical x-rays) is considered a full mouth x-ray. Total allowance for individual periapical x-rays, intraoral occlusal x-rays, extraoral x-rays and/or bitewing x-rays performed on the same day will not exceed the allowance for full mouth x-rays.Space maintainers are covered for premature loss of primary back teeth through age 13. e) Sealants are covered once per tooth in any 36 consecutive month period for permanent molars for children through age 14.f)

BASIC BENEFITSLimitations on Basic Benefits:

Ta) he same basic restorative service is covered once in any 12-month period for the same tooth.Composite fillings are covered on front teeth; amalgams on back teeth. Allowance will be made towards the cost of more expensive procedures. b) Treatment of teeth retained in relation to an overdenture is not covered.c) Surgical periodontal services are covered once in any 36-month period for the same quadrant, tooth or site; non-surgical services are covered once in any 24-d) month period for the same quadrant.Pulpotomy/pulpectomy is covered only for primary teeth.e) A course of treatment for apexification/recalcification (initial, interim, and final visits) is covered once per tooth.f)

MAJOR BENEFITSLimitations on Major Benefits - Special Restorative:

Special restorative services (ca) rowns, onlays and buildups) are covered once per tooth in any 60-month period.Any laboratory processed special restorative service or other special restorative service (except preformed shell crowns) is not covered for children under 12.b) Restorations posterior to the first molar will be limited to the allowance for a full metal restoration. c)

Limitations on Major Benefits - ProsthodonticPra) osthodontic appliances and services are covered once in any 60-month period for restorations involving the same tooth, including any prior special restorative service for the same tooth. Removable temporary partial dentures are a benefit to replace missing permanent front teeth.b) The surgical placement of implants is not covered. The placement of the crown, full or partial denture, or bridge over the implant is covered once in 60 c) months for restorations involving the same tooth. This limitation includes any prior special restorative or prosthodontic benefits for the same tooth.Fixed bridges (fixed partial dentures) and/or cast metal framework partial dentures (removable partial dentures) are not covered for persons under age 16.d) Fixed and removable prosthodontic appliances are not covered in the same arch. Allowance will be limited to the allowance for a removable appliance. e) Exception will be made when the fixed bridge (fixed partial denture) replaces front teeth.Reline or rebase of a prosthodontic appliance will be covered only once in any 36-month period. f)

ORTHODONTIC BENEFITS (ONLY if selected)Limitations on Orthodontic Benefits:

No a) benefits will be provided for:Replacement or repair of appliances.•Orthodontic care provided in the treatment of periodontal cases or cases involving treatment or repositioning of the temporomandibular joint.•

Periodic orthodontic payments will end upon termination of treatment for any reason prior to completion of the case, or upon termination of eligibility.b) For an orthodontic treatment plan started prior to the eligibility date of the patient, Delta Dental will begin periodic payments with the first payment due c) following the patient eligibility date. The maximum benefit will be determined based upon the prior payment history.

EXCLUSIONSThe following services are not benefits:

Sea) rvices for treatment of congenital (present at birth) or developmental (following birth) malformations, except intraoral dental services for treatment of a condition which is related to or developed as a result of cleft lip and/or cleft palate, unless otherwise included as a covered service.Services for cosmetic reasons.b) Services for restoring tooth structure lost from wear, erosion, attrition, abrasion, or abfraction.c) Services related to protecting, altering, correcting, stabilizing, rebuilding or maintaining teeth due to improper alignment, occlusion or contour.d) Services related to periodontal stabilization of teeth.e) Habit appliances, night guards, occlusal guards, athletic mouth guards and gnathological (jaw function) services, bite registration or analysis, or any f) related services.Pre-medication, analgesia, hypnosis or any other patient management services (except covered anesthetic services).g) Charges for prescription drugs.h) Any experimental or investigational procedures.i) Hospital costs and any additional fees charged by the dentist or hospital for hospital services or visits, or charges for use of any facility.j) Any anesthesia service not specifically included in covered services. k) Intraoral grafts when done in areas where a tooth/teeth are not present.l) Extraoral grafts (grafting of tissues or other substances from outside the mouth to or into oral tissues), augmentations or implants and/or any associated m) appliances. Removal of implants or any associated services.Myofunctional therapy or speech therapy.n) Services for the treatment of any disturbances of the temporomandibular joint (TMJ), facial pain, or any related conditions.o) Oral hygiene instructions or dietary instructions. Preventive control programs, including home care items.p) Completion of forms, providing diagnostic information or records, or duplication of x-rays or other records. Missed appointment charges.q) Replacement of lost, stolen or damaged appliances. r) Bone grafting when done in the same site as a tooth extraction, implant, apicoectomy or hemisection.s)

This form provides a brief description of limitations and exclusions. The Employee Benefit Booklet provides a more complete explanation of coverage, including limitations and exclusions.

Limitations & Exclusions Contributory Groups 5 - 100 Enrolled Employees

BOT_L&E_C5-100_102110

General InformationThe proposed rates are for the effective date as stated on the Rate Summary page of this quote. Final rates and whether coverage will be issued are subject to underwriting review. Underwriting reserves the right to re-evaluate rates based on any factors used to develop rates.

Quoted rates are valid for 100 or fewer •enrolled employees.Initial rate guarantee: 12 months.•Broker commissions: 8% Patient Direct; 10% •for groups 1-50; 5% for groups 51-100.Open enrollment is standard for voluntary plans.•Benefit-waitingperiodsforBasic,Majorand•Orthodontic services (if option chosen) are standard on voluntary and 1-4 enrolled options.LateEntrantProvisionswitha12-monthwaitforBasic,•Major,andOrthodonticservicesisstandardforallcontributory plans.Orthodontic services cover children to age 19 and •is available for groups with 25 or more enrolled employees.

Employer Contribution and ParticipationContributory: 50% Employer Contribution for the single employee premium with the greater of 1 or 50% of all eli-gible employees enrolled.Voluntary: 0-49% Employer Contribution for the single em-ployee premium with the greater of 5 or 20% of all eligible employees enrolled.

Declined IndustriesSIC/NAICSPEO7363/561330,PostOffice4311/491110,ProfSports7941/711211,Racing7948/711212,Dentistof-fices8021/621210,DentalLabs8072/339116,CivicSocialClubs8641/813410,PrivateHouseholds8811/814110,NationalSecurity9711/928110,InternationalAffairs9721/928120,PublicOrdersandSafety9229/922190, Nonclassifiable9999.

Dental Product InformationSingle choice and dual choice options are available.

Dual ChoiceAvailable for groups with 51-100 enrolled employees.•First plan is one of six core Small Group plans (contribu-•tory or voluntary). Second plan is Patient Direct.Contributory dual choice groups have late •enrollmentprovisions,andOpenEnrollmenttoswitchplans on their anniversary. Late Enrollment provisions willnotapply,ifswitchingtootherplan.Voluntary dual choice groups have waiting periods and •open enrollment provisions. Credit for waiting periods willbegivenfortimeenrolledinPatientDirectplan,ifswitching to other plan.

Payment and BillingPaymentbyACHisrequiredforallgroupswith •

less than 10 enrolled employees.Delta Dental of Colorado will bill the group •electronically.

Takeover Credit for Benefit Waiting PeriodsWillwaiveallwaitsforthosewhoenrollatinception,if•group has prior dental coverage within 30 days of their Delta Dental effective date.Proof of prior coverage is required (prior carrier’s bill •anddentalbenefitbooklet).Not offered to new hires.•

Late EnrollmentLate Enrollment means enrollment after the initial eligibility period (this does not apply to qualifying events). Late en-rolleesmustbeenrolledfor12monthsbeforeanybenefitsother than Diagnostic & Preventive will be covered.

Open EnrollmentMembersmayadddentalcoverageonceperyear. Benefitwaitingperiodsapply.

Out-of-State Employee GuidelinesCompany must be headquartered within Colorado. •Rates based on headquarters.•If less than 80% of employees are located in the home •state,thequotemustbesubmittedtoDeltaDentalofColorado Underwriting. PleasecontactDeltaDentalSales&Marketing(see•below) to submit a national quote.

Underwriting Guidelines Small Group—1 to 100 Enrolled Employees

Submit the following to enroll a group:

Group application

GroupHealthPlanCertification

Enrollment forms

ACHAuthorizationform(optional10-100)

EmployerConnectionAuthorizationform

Prior carrier bill/benefitbooklet(voluntary&1-4 groups only)

Copy of the sold original quote

One month’s premium

Federalwageandtax,ScheduleC(1-4 groups only)

qqqqqq

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Send completed forms and payment to:

Delta Dental of Colorado ATTN:Sales&Marketing4582S.UlsterStreet,Suite800Denver,CO80237

Phone: 303-741-9300 ext. 3300 Fax: 303-741-4233E-mail: [email protected]

1-100_UWGuidelines_010511

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Documents

Small Group · see any dentist, but claims will be paid according to the PPO schedule; therefore, it is in their best financial interest to visit a PPO dentist. Cost-conscious members