This dental plan offers you and your eligible family members comprehensive dental care through a convenient network of contract dentist in your state. There are no deductibles, no yearly limits on benefits or lifetime maximums, and there are no claim forms to fill out.
The dentists are screened to ensure that the plan standards of quality, access and safety are maintained. The network is composed of established dental professionals. This dental insurance plan provides coverage for one year. To enroll yourself or other eligible dependents you pay the annual premium and a one time enrollment fee. You choose your dentist from the online dentist directory during enrollment. Coverage is effective for 12 months and renewal is required to continue coverage.
Delta Dental must receive the enrollment materials by the 20th day of the month for coverage to be effective the first day of the following month. If Delta Dental receives the enrollment materials after the 20th day of the month, coverage will become effective the first day of the second month. This Enrollment and Payment Authorization Form and your check or money order, if applicable, must be received by the 20th day of the month for your coverage to be effective on the first day of the following month.
Detailed disclosure of plan co-payments, limitations and exclusions.
• See the Delta Dental insurance disclosure form -- click on the "Download Schedule of Benefits" image above.
1.The one-time enrollment fee is not refundable after the first month of coverage.
2.You, or your covered dependents, have not received any Benefits under the DeltaCare® USA program.
3.There is at least one month remaining in the Contract Term.
4.Coverage is based on a full calendar month. There are no partial month refunds.
Coverage for an enrollee will terminate as of the date enrollment is cancelled under the terms of the Disclosure Form/Contract. However, we will continue to provide benefits for completion of any treatment in progress (less any applicable co-payment). Cancellation of enrollment of a primary enrollee will automatically cancel the enrollment of a dependent enrollee. Any cancellation is subject to the written notification requirements set forth in the Disclosure Form/Contract. If coverage is voluntarily discontinued, you and your eligible dependents may not re-enroll during the 12-month period immediately following the voluntary termination.
DeltaCare® USA is underwritten in these states by these entities: AL Alpha Dental of Alabama, Inc.; AZ Alpha Dental of Arizona, Inc.; CA Delta Dental of California; AR, CO, IA, ME, MI, OK, OR, RI, SC, SD, WA, WI, WY Dentegra Insurance Company; NH and VT - Dentegra Insurance Company of New England; AK, CT, DE, FL, GA, KS, LA, MS, MT, TN, WV and Washington, D.C. Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX Alpha Dental Programs, Inc.; NV Alpha Dental of Nevada, Inc.; UT Alpha Dental of Utah, Inc.; NM Alpha Dental of New Mexico, Inc.; NY Delta Dental of New York; PA Delta Dental of Pennsylvania. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states, except CA. These companies are financially responsible for their own products.
You must receive treatment from your selected network facility in order to receive benefits. Your facility may refer you to a network specialist for specialty care treatment. Specialty care treatment received from a dental school clinic may be provided by a dental provider, a dental student, a clinician or dental instructor.
You will receive a list of up to 100 DeltaCare USA network offices nearest to you. The number of dental providers displayed depends on the address and availability of dental providers in that area. After making a selection from the results list, note the office number to include on your enrollment application. Once you are eligible on the plan, you will receive an identification card and an Evidence of Coverage booklet describing your benefits.
You can make an appointment once you have received confirmation of your enrollment.
• If you are currently enrolled in the DeltaCare USA program, you may transfer to another facility by completing the online customer service request form.
• Delta Dental must receive the DeltaCare USA enrollment materials and/or facility change request by the 20th day of the month for coverage to be effective the 1st day of the following month.
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