YORK COUNTY SCHOOLS

Open Enrollment for Plan Year 2021

Delta Dental Benefit Plans

Delta Dental PPO Plus PremierTM

Access to all networks: Premier, PPO and out-of-network statewide and national

Delta Dental PPOTM – EPO Plan Design PPO dentist network only statewide and national

With York County School’s PPO Plus Premier plan option members have two networks to choose from (Premier, PPO and also out of network); the EPO option offers the PPO network only (no out of network);

Delta Dental Premier® – This is Delta Dental’s largest network and provides the greatest access to care.This network includes approximately 84% of Virginia dentists.

Delta Dental PPOSM – The PPO network provides our deepest discounts and the lowest out-of-pocket costs. 55% of Virginia dentists participate.

Members can go out-of-network in the PPO Plus Premier Plan only, but will receive the greatest savings when they choose a dentist that participates in one of our networks.

Out-of-Network-Freedom to go to

any licensed dentist -Highest out-of-pocket costs

$Delta Dental Premier

-Broadest network-Higher out-of-pocket

costs than PPO

$Delta Dental PPO-Narrower network

-Lowest out-of-pocket costs

$

How Delta Dental’s Networks Work

PPO NETWORK PREMIER NETWORK OUT-OF-NETWORK

Diagnostic and Preventive Services(cleaning, exam, fluoride, bitewings)

100% PPO Allowance

100%Premier Allowance

100% Non-Par Allowance

Basic Services(fillings, extractions, root canals, periodontics, oral surgery)

80% PPO Allowance

80%Premier Allowance

80%Non-Par Allowance

Major Services(crowns, dentures, bridges, Implants)

50% PPO Allowance

50%Premier Allowance

50%Non-Par Allowance

Orthodontic Services (for subscriber and covered dependents)

50% PPO Allowance

50%Premier Allowance

50%Non-Par Allowance

Annual Deductible $50/$150 $50/$150 $50/$150

MaximumsContract YearLifetime Orthodontic

$1,500$1,500

$1,500$1,500

$1,500$1500

Delta Dental PPO Plus Premier™Option 1

PPO NETWORK PREMIER NETWORK OUT-OF-NETWORK

Diagnostic and Preventive Services Fixed copay No Coverage No Coverage

Basic Services Fixed copay No Coverage No Coverage

Major Services (crowns, dentures, bridges) Fixed copay No Coverage No Coverage

Orthodontic Services (for subscriberand covered dependents) 50% No Coverage No Coverage

Annual Deductible None N/A N/A

MaximumsContract YearLifetime Orthodontic

$1,500$1,500 N/A N/A

Delta Dental PPO™ – EPO Plan DesignOption 2 (PPO Network Only)

PPO Plus Premier and EPO-PPO Benefit DifferencesP PPO Plus Premier

Option 1PPO – EPO PlanOption 2

Provider Network PPO, Premier and Out of Network PPO Network Only

Deductible $50 /$150 applies to Basic and Major Services Only No Deductible

Provider Payment Co-Insurance Fixed Copays based on Scheduleexcept for Orthodontics

Full-mouth X-rays (D&P) Once in 5 years Once in 3 years

White/composite fillings (Basic) On ALL teeth On front 6 teeth, upper and lower

Implants Covered in Major Services at 50% Not Covered

Prevention First Included Not Included

Periodontal Cleaning Twice in a Calendar Year in addition to two regular cleanings and oral exams

Twice in a Calendar Year – either a periodontal cleaning or a regular cleaning;

Lab Fees Included in cost of Crown, Denture, Bridge

Not included in fixed copay for Crown, Denture, Bridge

PPONetwork

PremierNetwork

Out-of-Network

Dentist Charge $215 $215 $215

Plan Allowance $126 $169 $152

Coinsurance Amount 80% 80% 80%

Delta Dental Payment $100.80 $135.20 $121.60

Patient Payment $25.20 $33.80 $93.40

*This example is for illustrative purposes only and assumes that the annual deductible has been met.

PPO Plus Premier Plan Payment Example*

PPO Network Premier Network Out-of-NetworkDentist Charge $215 $215 $215

Plan Allowance $126 $0 $0

Patient Copayment $25.20 0% 0%

Delta Dental Payment $100.80 $0 $0

Patient Payment $25.20 $215 $215

*This example is for illustrative purposes only.

Delta Dental PPO™ - EPO Plan Design Payment Example*

Prevention First – PPO Plus Premier Product Only

Diagnostic and Preventive Treatment (twice annually)

Delta DentalPays

MemberPays

MaximumRemaining

$190 $0 $1,310

With Prevention First

Diagnostic and Preventive Treatment (twice annually)

Delta DentalPays

MemberPays

MaximumRemaining

$190 $0 $1,500

Cleanings and preventive visits are covered at your plan’s current level…and the costs for these services will not count against your annual benefit maximum!

This means that you will always have benefits for these services, even if you have used all of your annual maximum benefit allowance. Here is an example* on how the Prevention First benefit works:

*Dentist charges may vary. Rates vary depending on your plan type.

Pre-Determination of Benefits

• Recommended – but not required• For services of $250+• Process:

– Dentist submits to Delta Dental to include proposed treatment plan– Delta Dental processes like a claim form (turnaround time 5-7 business days )– Statement mailed to dentist and subscriber – indicating reimbursement amount

Allows members to make an informed decision prior to having services rendered!

• You will receive two ID cards. At your first appointment, show your dentist your new ID card. If your dentist participates in our networks, your dentist will file your claims for you.

• If your dentist does not participate, you may have to pay your dentist upfront and file for reimbursement. Claim forms may be found at DeltaDentalVA.com.

• If you have questions, call customer service at 800-237-6060. Representatives are available:

- 8:15 am to 6:00 pm; Monday through Thursday- 8:15 am to 4:45 pm; Fridays

(Eastern Times noted)

Delta Dental PPOplus Premier

Group Name: Newport News Public Schools Number: XXXXXXSubscriber Name: John DoeIdentification No: 00000000000000Membership Type: FamilyEffective Date: 01/01/2021For Benefit Services: 800-237-6060

www.deltadentalva.com

After You Enroll

Check Out Our Website: DeltaDentalVA.com

No login necessary to:Find a dentist Website Tutorials

It’s Easy to Find a Network Dentist

From the home page scroll down to the Find a Dentist section.You can enter specialty, plan, distance and zip code to search for a participating provider in your area.

You do not need to log in to perform a dental search.

www.DeltaDentalVA.com

Secure Members Page:

• Replacement ID Cards

• View Your Benefits

• Cost Estimator Tool

• Claims Information

• Download forms

• Live Chat with Customer

Service

JOHN DOEABC COMPANY

00000712345-000000001-000000001

510000XXXXXXXX-01FAMILY

4 MEMBERS07/01/2020

JOSEPH R. SMITH DDS

123 APPLE LANESUFFOLK, VA 23435

YES/IN-NETWORKGET DIRECTIONS

757-123-4567

Mobile App

Members can log into the free Delta Dental mobile app using the same website login information. Once logged in:• Check coverage and review claims

information• View, print and email your ID card• Use our Cost Estimator Tool

QUESTIONS?

Benefit Services1-800-237-60608:15AM – 6:00 PM (Monday – Thursday)8:15AM – 4:45 PM EST (Friday)

The Delta Dental Difference®

Fulfilling our mission of providing affordable oral healthcare to all.

We are the dental experts.