Dental Plan

How Your Dental Plan Works 

The Claim Administrator (Delta Dental) maintains a nationwide network of participating dentists. Each time you or an eligible dependent needs dental care, you can choose: 

  • a network dentist; or
  • an out-of-network dentist.          

ANNUAL DEDUCTIBLE
The annual deductible is the amount you pay before benefits for basic and major restorative dental services start. The annual deductible applies only once in any calendar year, even though you may have a number of different courses of treatment during the year. 

You do not have to pay an annual deductible for diagnostic or preventive dental services, such as routine exams or cleaning.

Amount of Deductible
The amount of the annual deductible is $50 for each covered person, with a family maximum of three individual deductibles ($150) each calendar year. 

Family Maximum: Once three covered family members have each met their individual $50 annual deductibles for a given calendar year, the deductibles for all of your other covered family members will be waived for the rest of that year. 

MAXIMUM ANNUAL BENEFIT
The maximum amount that the plan will pay in any calendar year is as follows: 

Standard Plan
$1,500 per person

High Option Plan
$2,000 per person 

After a covered person reaches the maximum benefit in a calendar year, the plan will not pay any additional benefits for that person for the rest of the year.

Treatment received after you exhaust your calendar year maximum may be billed at the dentist's normal fee rather than Delta Dental's negotiated fee. 

Orthodontic Care: Benefits for orthodontic care are subject to a separate lifetime maximum of: 

Standard Plan
$1,500 per covered person

High Option Plan
$2,000 per covered person

ROLLOVER MAXIMUM BENEFIT
The Rollover Max allows you to rollover a portion of your unused maximum annual benefit in one year to increase your maximum benefit for the following year and beyond. To qualify for a Rollover Max, members must meet the following requirements: 

Standard Plan:

  • You must receive at least one cleaning or one oral exam in the plan year;
  • Your paid claims must not exceed the maximum “threshold” amount ($700.00) of your current annual plan maximum ($1,500.00);
  • Annual maximum dollars are used first. Rollover Max dollars are used after the annual maximum is met;
  • Rollover Max does not apply to the lifetime maximum for orthodontia. 

The chart below is a four-year example of how Rollover Max is applied based on a member’s annual maximum amount of $1,500: 

  Year One Year Two Year Three Year Four
Your annual maximum amount $1,500 $1,500 $1,500 $1,500
Rollover Amount from previous year N/A $500 $500 $250
Benefit dollars available $1,500 $2,000 $2,000 $1,750
Your total claims paid* $400
(Less than $700)
$900
(Over $700)
$1,750**
(Over $700)
$500
(Less than $700)
Cleaning or oral exam during year Yes Yes Yes Yes
Rollover amount $700 $0 $0 $500
Accumulated Rollover Max Total $500 $500 $250 $750

*In this example, “Your total claims paid” cannot exceed the threshold amount ($700) based on the annual maximum amount of $1,500. In order to qualify for Rollover Max, your total claims paid must not exceed the designated “threshold” amount for your plan’s annual maximum amount and the claims must include at least one oral exam or cleaning. Reference the second column of the chart below for your dental plans “threshold” amount. 

**In year three, the $1,500 annual maximum was exceeded, but the member had enough Rollover Max dollars accumulated ($500) to cover the additional $250 cost. 

High Option Plan:

  • You must receive at least one cleaning or one oral exam in the plan year;
  • Your paid claims must not exceed the maximum “threshold” amount ($800.00) of your current annual plan maximum ($2,000.00);
  • Annual maximum dollars are used first. Rollover Max dollars are used after the annual maximum is met;
  • Rollover Max does not apply to the lifetime maximum for orthodontia. 

The chart below is a four-year example of how Rollover Max is applied based on a member’s annual maximum amount of $2,000: 

  Year One Year Two Year Three Year Four
Your annual maximum amount $2,000 $2,000 $2,000 $2,000
Rollover Amount from previous year N/A $600 $600 $350
Benefit dollars available $2,000 $2,600 $2,600 $2,450
Your total claims paid* $400
(Less than $800)
$900
(Over $800)
$2,250**
(Over $800)
$600
(Less than $800)
Cleaning or oral exam during year Yes Yes Yes Yes
Rollover amount $800 $0 $0 $600
Accumulated Rollover Max Total $600 $600 $350 $950

 *In this example, “Your total claims paid” cannot exceed the threshold amount ($800) based on the annual maximum amount of $2,000. In order to qualify for Rollover Max, your total claims paid must not exceed the designated “threshold” amount for your plan’s annual maximum amount and the claims must include at least one oral exam or cleaning. Reference the second column of the chart below for your dental plans “threshold” amount. 

The chart below shows how Rollover Max is calculated based on your annual maximum benefit levels: 

Dental Plan Option Your plan's annual maximum benefit amount If your total yearly claims don't exceed this threshold amount Then you can roll over this amount to use next year, and beyond Your accumulated rollover total is capped at this amount
Standard $1,500 $700 $500 $1,250
High Option $2,000 $800 $600 $1,500
  • If you disenroll from your plan (for example, if you marry and enroll under your spouse’s plan), you will lose your current rollover balance/amount.
  • If you enroll after the beginning of the 4th quarter of the benefit period, you will not be eligible to begin rollover accrual until the beginning of your next benefit period.
  • Claims not received by the last day of the calendar year may affect any Rollover Max benefit dollars available in the following year. If claims for services covered in the prior year are received after the date the maximum is calculated, the calculation will be adjusted accordingly. 

IDENTIFICATION CARD
When you join the Dental Plan, you will receive a plan identification card. This card will identify you as a plan member and (in most cases) expedite the claim filing process. Your ID card will also identify you as a member of a dental care plan that uses the Delta Dental network (see Network Care for details). 

If you lose or misplace your ID card, you can obtain a replacement by calling Delta Dental’s Customer Service Department at 1-800-872-0500. You can also log on to their website at www.deltamass.com. 

PRE-TREATMENT PLAN
If you anticipate having dental expenses of $300 or more, your dentist should submit a written pre-treatment plan before a course of dental treatment begins. By submitting the treatment plan before work begins, both you and your dentist will know in advance the benefits that are available for the prescribed treatment. 

You or your dentist can obtain a pre-treatment plan form by calling 1-800-872-0500 or writing Delta Dental at: 

Delta Dental of Massachusetts
465 Medford Street
Boston, MA 02129 

There may be more than one way to treat a dental condition. In determining the amount of benefits payable, Delta Dental may consider an alternate procedure that will accomplish a professionally satisfactory result, but is less costly than the submitted treatment. Regardless of the treatment actually rendered, plan payments may not exceed the amount payable for the least costly professionally satisfactory method of treatment.

NETWORK CARE
You can save time and money by using Delta Dental’s nationwide network of participating dentists, which includes: 

  • the Delta Dental PPO Network; and
  • the Delta Dental Premier Network

In general, you receive the greatest value when you visit a PPO dentist, because PPO dentists charge the lowest fees for their services (compared to Premier or out-of-network dentists). You also enjoy a cost savings when you visit a Premier Network dentist (compared to out-of-network care). 

Network Advantages
Using a Delta Dental PPO or Premier dentist gives you a number of important advantages: 

Cost Savings: Delta Dental PPO and Premier dentists charge discounted fees for their services. Since the amount you pay is based on these discounted fees, your out-of-pocket costs are generally lower (compared to out-of-network care). 

No Claim Forms: There are no claim forms to fill out when you use a Delta Dental PPO or Premier dentist. 

Direct Payment: Delta Dental pays participating PPO and Premier dentists directly, so you do not have to pay the dentist’s fee and then wait for a reimbursement check. 

You can locate Delta Dental PPO Network and/or Premier Network dentists in your area by contacting Delta Dental Customer Service at 1-800-872-0500. You can also log on to their website at www.deltamass.com.

OUT-OF-NETWORK CARE
Your out-of-pocket costs will generally be higher if you use an out-of-network dentist (i.e., a dentist that does not participate in the PPO or Premier networks). If you use an out-of-network dentist: 

  • you must pay the dentist’s fee directly;
  • you must complete a claim form and submit your claim to Delta Dental (see Filing Your Claim); and
  • you will be reimbursed for the amount covered by the plan. 

Amount of Reimbursement 

If you use an out-of-network dentist, the plan will reimburse you for the portion of the dentist’s fee which: 

  • is for a covered dental expense (see Covered Dental Expenses);
  • does not exceed annual or lifetime plan maximums;
  • does not exceed the customary charge* for the service;
  • is for a service that is necessary and appropriate for your condition; and
  • is for a service that is not limited or excluded by the plan (see Exclusions and Limitations). 

*based on what other providers in your area charge for the same service 

You can call Delta Dental Customer Service at 1-800-872-0500 if you have any questions or need assistance in estimating the amount of your plan reimbursement for out-of-network care.


How Plan Benefits Are Paid

The amount that the Dental Plan will pay depends on: 

  • your dental option (Standard or High);
  • the type of dental service that you receive; and
  • whether you use a network or out-of-network dentist.       

COVERED EXPENSES
The Dental Plan covers a wide range of dental expenses, including: 

  • Preventive and Diagnostic (oral exams, teeth cleaning, X-rays, etc.)
  • Basic Restorative (fillings, oral surgery, treatment of gum disease, etc.)
  • Major Restorative (dentures, crowns, bridges, etc.)
  • Orthodontics to age 19 (teeth straightening) 

For a more complete description of covered expenses, see the Covered Dental Expenses charts below. 

PLAN PAYMENT
The following chart summarizes what the plan will pay for each type of covered expense: 

Type of Service Standard Plan Payment
(in or out-of-network)
High Option Plan Payment
(in or out-of-network)
Preventive and Diagnostic 100% of covered expenses
(no deductible)
100% of covered expenses
(no deductible)
Basic Restorative 80% of covered expenses after annual deductible 90% of covered expenses after annual deductible
Major Restorative 50% of covered expenses after annual deductible 60% of covered expenses after annual deductible
Orthodontic to age 19 50% of covered expenses
(no deductible)
($1,500 per person lifetime maximum)
50% of covered expenses
(no deductible)
($2,000 per person lifetime maximum)

YOUR PAYMENT
The plan pays 100% of covered expenses for preventive and diagnostic services, with no deductible. Your cost for other covered services will depend on: 

  • the type of service you receive (e.g., basic restorative or major restorative); and
  • whether you use a network or out-of-network dentist. 

It will be to your advantage to use a Delta Dental network (PPO or Premier) dentist whenever possible. This is because network dentists will not charge more than the scheduled (discounted) fee for a given dental service. This fee is generally lower than the fee charged by out-of-network dentists.

You will enjoy the highest cost savings when you use a PPO dentist: 

  • PPO Dentists generally charge the lowest fees (compared to Premier or out-of-network dentists);
  • Premier Dentists generally charge lower fees (compared to out-of-network dentists); and
  • Out-of-Network Dentists generally charge the highest fees (compared to PPO or Premier dentists). 
Your dentist must submit a pre-treatment plan for covered procedures that are expected to exceed $300. This plan will include a description of the planned procedure(s) and an estimate of your dentist’s charges for each procedure. Upon receipt of the treatment plan, Delta Dental will notify you and your dentist of the maximum benefits available to you for each procedure.

PLAN PAYMENT: HERE IS AN EXAMPLE
To illustrate how using a network dentist can save you money, assume that you need a tooth filled, and: 

  • the customary charge* for this service is $175;
  • the PPO Network charge for this service is $122;
  • the Premier Network charge for this service is $157; and
  • you have not met the annual deductible. 

*based on what other providers in your area charge for the same service 

Here is how your plan benefit would be determined using the Standard Plan as an example: 

  PPO Dentist Premier Dentist Out-of-Network Dentist
Dentist’s Fee $120 $150 $175
Annual Deductible ($50) ($50) ($50)
Expenses After Deductible $70 $100 $125
Plan Pays This Amount

(80% x expenses after deductible)
$56 $80 $100
You Pay This Amount* $64 $70 $75

*your $50 annual deductible, plus 20% of expenses after deductible 

PAYMENTS MADE IN ERROR
The plan has the right to request a refund if it makes an overpayment of your benefits. This refund may be requested from you or your dentist, as appropriate.