Getting the Most Out of the Delta Dental PPO Plan

The Delta Dental PPO Plan has been in place for over a year now. The following tips will help you maximize the dental benefits you receive from this plan:

Tip 1

Use a Delta Dental PPO participating dentist in order to receive the maximum benefits. If you are not sure if your dentist is a Delta Dental PPO participating dentist, you can find out in 1 of 3 ways:

  1. Call your dentist's office and ask if your dentist belongs to the Delta Dental PPO network. Be sure to use your dentist's full name. Ask, "Does Dr. Fred Jones belong to the Delta Dental PPO network?" Don't just ask if the office or if Dr. Jones belongs to Delta Dental, because Delta Dental has different networks and because dentists join the Delta Dental PPO network as individual dentists, not as members or partners in a dental office or dental practice.

 OR

  1. Check the Delta Dental PPO provider network on-line using your computer. You can log onto Delta Dental website at www.deltadentalins.com. On the home page, under the drop-down menu for "Find A Dentist" select "Delta Dental PPO" as the plan and then "Search." After you select "California" as the state, you will be able to search the Delta Dental PPO Provider Directory to look for a dentist by location or by name. If your dentist's name and address does not appear in the search results, then your dentist does not belong to the Delta Dental PPO network.

 OR

  1. Call Delta Dental's membership services department. Their telephone number is 1-800-765-6003. Enter option 2 and then enter 0 #. This will put you on the telephone with a live person who can determine if your dentist is a Delta Dental PPO dentist or not. Be sure to give the member services representative your dentist's full name and the address where you receive dental services.

Tip 2

The Delta Dental PPO Plan gives you the freedom to go to any licensed dentist to receive your dental care. However, you will get the most out of your dental benefits if you use a Delta Dental PPO participating dentist (see Tip 1 above). Even if your dentist doesn't belong to the Delta Dental PPO network, he or she may still belong to the Delta Dental Premier network. If so, you will still benefit from the plan, because your dentist agrees to accept Delta Dental's fee schedule which limits the amount you can be charged for the services you receive, and which also limits the amount you will have to pay out of pocket after the Delta Dental PPO Plan has paid its benefits. Whenever you can, make sure your dentist belongs to either the Delta Dental PPO network or to the Delta Dental Premier network.

The following 3 examples show how using a Delta Dental PPO dentist maximizes your dental benefits and reduces your out-of-pocket expense. They also illustrate that even going to a Delta Dental Premier dentist saves you money compared to going completely out of the Delta Dental provider networks.

Tip 3

Be sure to get routine dental care twice a year. Having regular and periodic dental checkups and cleanings can help identify dental problems before they become major expenses. A little prevention goes a long way in promoting and maintaining your dental health.


Example 1
Teeth Cleaning (Adult Prophylaxis)
Out-of-Network payment is based on Delta Dental's PPO Fee Allowance.

(This example is for illustration purposes only.)

Teeth Cleaning—The Delta PPO Plan's benefit is based on the Delta PPO Fee Allowance, paid at the percentage shown Delta PPO Dentist

100%
Non-PPO
Delta Premier Dentist


100%*
Non-PPO
Non-Delta Dentist


100%*
Dentist Charges $87.00 $87.00 $87.00
Dentist's Contracted Fee $64.00 $77.00 Not Applicable—because the dentist does not belong to the Delta Dental network
Plan Allows $64.00 $64.00 $64.00
Plan Pays $64.00 (100%) $64.00 (100%) $64.00 (100%)
Patient Pays $0 $13.00* $23.00*
Is Balance Billing to patient allowed? NO YES YES
Comments Because the dentist is a Delta PPO dentist, the patient pays the difference between the most the dentist can charge under the Delta Dental contract and what Delta pays:
$64.00 - $64.00 = $0.00
Because the dentist is a Delta Premier dentist, the patient pays the difference between the most the dentist can charge under the Delta Dental contract and what Delta pays:
$77.00 - $64.00 = $13.00
Because the dentist does not contract with Delta Dental, the patient pays the difference between what the dentist charges and what Delta pays:
$87.00 - $64.00 = $23.00

* You will incur greater out-of-pocket expenses if you use a dentist who does not belong to the Delta Dental PPO Network.


Example 2
Root Canal on a Molar Tooth
Out-of-Network payment is based on Delta Dental's PPO Fee Allowance.

(This example is for illustration purposes only.)

Root Canal—The Delta PPO Plan's benefit is based on the Delta PPO Fee Allowance, paid at the percentage shown Delta PPO Dentist

95%
Non-PPO
Delta Premier Dentist


80%*
Non-PPO
Non-Delta Dentist


80%*
Dentist Charges $882.00 $882.00 $882.00
Dentist's Contracted Fee $606.00 $625.00 Not Applicable—because the dentist does not belong to the Delta Dental network
Plan Allows $606.00 $606.00 $606.00
Plan Pays $575.70 (95%) $484.80 (80%) $484.80 (80%)
Patient Pays $30.30 $140.20* $397.20*
Is Balance Billing to patient allowed? NO YES YES
Comments Because the dentist is a Delta PPO dentist, the patient pays the difference between the most the dentist can charge under the Delta Dental contract and what Delta pays:
$606.00 - $575.70 = $30.30
Because the dentist is a Delta Premier dentist, the patient pays the difference between the most the dentist can charge under the Delta Dental contract and what Delta pays:
$625.00 - $484.80 = $140.20
Because the dentist does not contract with Delta Dental, the patient pays the difference between what the dentist charges and what Delta pays:
$882.00 - $484.80 = $397.20

* You will incur greater out-of-pocket expenses if you use a dentist who does not belong to the Delta Dental PPO Network.


Example 3
Crown—Full Cast Gold Crown
Out-of-Network payment is based on Delta Dental's PPO Fee Allowance.

(This example is for illustration purposes only.)

Full Cast Gold Crown—The Delta PPO Plan's benefit is based on the Delta PPO Fee Allowance, paid at the percentage shown Delta PPO Dentist

75%
Non-PPO
Delta Premier Dentist


50%*
Non-PPO
Non-Delta Dentist


50%*
Dentist Charges $920.00 $920.00 $920.00
Dentist's Contracted Fee $693.00 $786.00 Not Applicable—because the dentist does not belong to the Delta Dental network
Plan Allows $693.00 $693.00 $693.00
Plan Pays $519.75 (75%) $346.50 (50%) $346.50 (50%)
Patient Pays $173.25 $439.50* $573.50*
Is Balance Billing to patient allowed? NO YES YES
Comments Because the dentist is a Delta PPO dentist, the patient pays the difference between the most the dentist can charge under the Delta Dental contract and what Delta pays:
$723.00 - $542.25 = $180.75
Because the dentist is a Delta Premier dentist, the patient pays the difference between the most the dentist can charge under the Delta Dental contract and what Delta pays:
$995.00 - $361.50 = $633.50
Because the dentist does not contract with Delta Dental, the patient pays the difference between what the dentist charges and what Delta pays:
$1,345.00 - $361.50 = $983.50

* You will incur greater out-of-pocket expenses if you use a dentist who does not belong to the Delta Dental PPO Network.

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