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Dental Product Guide

Dental Product Guide

Dental insurance for employers with 2 to 49 enrollees

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2 |Page 3 |Page

For 2012, Delta Dental has turned its small-group product line upside down. We’ve not only enhanced our products; we’ve changed the way we promote them and communicate them to employees. In fact, we’ve changed just about everything except the great Delta Dental service that comes with every plan we sell.

Here are some of the things we’ve changed for 2012:

• Money-saving MAC (Maximum Allowable Charge) options for our most

popular plans

• A new table-of-allowances plan

• Voluntary versions of our popular 2-4-enrolled contributory products • A greater emphasis on increasing enrollment, with new employee-facing

materials and enrollment strategies

• A new website, set to launch in late 2012 • An improved online quoting tool

• New collateral materials

Our small-group plans are backed by our strongest commitment ever to this crucial

market segment. And it’s the foundation for even greater things to come.

Dave Peterson

Vice President, Sales and Marketing

— and learn how their dedication and expertise have made

Delta Dental Wisconsin’s No. 1 choice for dental benefits.

experience.deltadentalwi.com

SHOWN AT LEFT (front to back): David Peterson (Vice President, Sales and Marketing), Tom Williams (Sales, Northern and Western WI), Tracy Thiel (Account Management, Milwaukee and Southeastern WI), Lynn Horn (Account Management, Milwaukee and Southeastern WI), Jackie Bloomer (Sales, Fox Valley, Madison, Milwaukee and Southeastern WI), Michelle Czaplinski (Underwriting), Rick Zupan (Manager, Sales, Statewide), Michele Knoll (Account Management, Northern and Western WI), Scott Meyer (Actuary), Jenny Wydeven (Account Management, Madison), Denny Peterson (Executive Vice President)

SMALL-GROUP TEAM NOT SHOWN: Becki Giese (Account Management, Fox Valley), Andy Wavrunek (Sales Support, Statewide), Megan Wolff (Sales Support, Statewide)

Meet the people of

Delta Dental of Wisconsin

Relax, we’ve got you covered.

Relax, we’ve got you covered.

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4 |Page 5 |Page

Our commitment to employers includes...

Networks:ours are bigger.

The Delta Dental PPO has the most verified locations of any Wisconsin

PPO network, and the Delta Dental Premier network is the state’s

largest dentist network. They worked

together to save Wisconsin groups more than $56 million in 2011.

service:ours is better.

Agents, employers, members, and

dentists agree: Delta Dental has the best service of any Wisconsin

dental-benefits provider. In our

latest survey, Delta Dental’s

satisfaction rate topped 94 percent! Delta Dental answers the phone

quickly, provides expert assistance,

and resolves most claim issues with just one call.

kNowledge:we kNow

what you waNt.

We only do business in Wisconsin, with Wisconsin-based employers. We understand the market and the competition and the plans and the

people. Our products reflect that knowledge. They’re created specifically for you and your

business, serviced by Wisconsin people, using a network made in Wisconsin.

expertise:we have more.

Delta Dental started providing

dental benefits in Wisconsin 50

years ago. No one knows more

ways to make dental benefits work

harder for you.

philaNthropy:we take

care of wiscoNsiN.

Delta Dental’s mission is to improve

access to quality oral healthcare

for all Wisconsin residents. Do any other dental-insurance companies have a mission like that?

research:we support it,

aNd we put it to work.

Delta Dental supports ground-breaking oral-health research in Wisconsin and around the world. We’re already looking at the future

of dental benefits, and we’re going

to lead the way.

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6 |Page 7 |Page 61% 2% 25% 12% $50 $25 $0 Other 58% 6% 9% 20% 6% 1% $1,200 $1,500 $2,000 Other $1,000 $750 85% 10% 1% 4% 80% 90% 100% Other 81% 9% 2% 4% 60% 80% 100% Other 50% 4%

Plan design:

61% choose a $50 deductible.

Annual maximum:

58% choose a $1,000 annual maximum.

Basic services:

85% choose an 80% copay in-network; (78% choose an 80% copay out-of-network.)

Major services:

81% choose a 50% copay in-network; (74% choose a 50% copay out-of-network.)

Setting a dental insurance rate requires that many factors be weighed. Everything has to be in balance,

or the end result could be disastrous.

Delta Dental weighs many factors when setting its small-group rates – overall experience, dentist discounts, type of business, single-family mix, and many more. One of the most important group-

specific factors used in small-group rating is

employee participation.

The greater the percentage of people in a group

enrolling in the dental plan, the more the risk is spread and the lower the rate.

Delta Dental’s best rates are reserved for its highest-participating groups, and that means we may have

to ask you more frequently for participation and contribution information. Great information makes

great rates, and your assistance in gathering this information makes it possible.

Delta Dental has a dedicated worksite-marketing

program to help your organization improve employee

participation. We can help you coordinate effective employee meetings with the tools to get the job done: pre-enrollment materials, employee-facing enrollment materials, easy signup, and a follow-up program.

Making a great rate.

What Wisconsin wants.

What Wisconsin wants is Delta Dental. Our plans have been Wisconsin’s favorites for 50

years. And when it’s time to choose a Delta Dental plan, here’s what Wisconsin groups

just like yours choose.

With this information, you can go along with the crowd or blaze your own trail. Either

way, Delta Dental has you covered.

The answer is balance.

Making a great rate.

What Wisconsin wants.

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8 |Page 9 |Page

Delta Dental Table of Allowances Plan

With a Delta Dental Table of Allowances plan, there’s no question what the insurance company pays. The plan schedule lays out what Delta Dental pays for virtually all popular dental procedures.

what is a table-of-allowances plan?

A table-of-allowances plan lists what the plan pays for a given procedure. The more procedures covered, and the more the insurance company pays for a procedure, the better the plan.

what are the advantages of a

table-of-allowances plan?

Rates for table-of-allowances plans remain extremely stable over time because the plans aren’t priced by utilization but instead are driven by the composition of the tables. The dollar amounts paid out by the plans don’t change unless the tables change. Because the tables can be set at any amount, the plans can be made to be very affordable at the outset – and stay very affordable over time.

A table-of-allowances plan is great for employers who

want to provide a benefit but feel they can’t afford a

traditional plan, or employers who offer an employee-paid option and feel their employees may struggle to pay the premiums of a traditional plan.

what plans are similarly priced?

For roughly the same price† you can choose:

A Delta Dental UltraSavings PPO plan.

(See page 10)

No matter where dental costs go,

Table of Allowances plan rates tend to stay the same.

who is the table of allowances plan for?

Groups looking for immediate and long-term savings. Groups located in areas

where there are a lot of Delta Dental PPO dentists.

Groups where employees pay some or all of the premium.

This plan is

best for:

delta dental table of allowances plan

Delta Dental Table of Allowances Plan

Delta Dental’s most affordable plan.

Note: There is a tradeoff to a table-of-allowances plan: As dental costs go up, your out-of-pocket costs may increase as well. Consider seeing a Delta Dental PPO dentist to minimize the impact of rising dental costs.

Waiting periods also apply for groups with no existing dental plan, and for enrollees who waive coverage initially, drop coverage, or become eligible for the plan after the initial enrollment period (new hires or qualifying events). There is a six-month waiting period for endodontics (root canals), periodontics (gum-disease treatment), extractions, and oral surgery, and a 12-month waiting period for crowns, implants, complete and partial dentures, fixed bridges, and repairs and adjustments. There is no benefit waiting period for diagnostic and preventive services, or basic restorative services. For groups with an existing dental plan, there are no waiting periods for those enrolling during the initial enrollment period.

As the standard table-of-allowances plan.

A penny saved is a

penny... well, saved!

Member Benefit

Deductible Options – Individual/Family (applies to all procedures) $50/$150

Individual Annual Maximum $1,000

Diagnostic & Preventive Services

Examinations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays every five years.

One-time application of sealants. Space maintainers as needed.

Plan pays up to the table of allowances amount for specific

services until the annual maximum is reached. See the full

table of allowances for covered procedures and covered amounts.

Basic Restorative Services

Emergency treatment to relieve pain, fillings.

Major Restorative Services

Endodontics and periodontics (root canals and gum-disease treatment), extractions, oral surgery,

crowns, complete and partial dentures, implants, fixed bridges, repairs and adjustments.

Dependent Age Limitation Dependents covered

to age 26

Vision-Care Discount Program Included

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10 |Page 11 |Page

A plan that maximizes Delta Dental’s PPO savings.

Delta Dental’s UltraSavings PPO delivers an

affordable-yet-ample benefit for members who see a Delta

Dental PPO dentist from the state’s largest PPO dentist network*.

what is the ultrasavings ppo?

The UltraSavings PPO combines an innovative

in-network PPO benefit with an out-of-network benefit that encourages members to see a Delta

Dental PPO dentist, while still covering their basic dental needs.

what else is included?

Each Delta Dental UltraSavings PPO includes:

CheckUp Plus™:

Diagnostic and preventive services don’t count against your annual maximum with CheckUp Plus™.

Evidence-Based Integrated Care Plan (EBICP):

The industry-leading benefit enhancement for

whole-body health, EBICP covers additional cleanings for pregnant women, diabetics, and people with other health conditions. See www.deltadentalwi.com/EBICP for more information.

mac plan option

In addition to your choice of annual maximum and deductible, a MAC (Maximum Allowable Charge) plan option is available, but not required. With a MAC plan, members pay a lower rate, but out-of-pocket expenses can be higher when they see a dentist other than a Delta Dental PPO dentist.

what plans are similarly priced?

For roughly the same price† you can choose:

A Delta Dental Table of Allowances plan.

(See page 8)

who is the ultrasavings ppo plan for?

Groups looking for immediate and long-term savings. Groups located in areas

where there are a lot of Delta Dental PPO dentists.

Groups where employees pay some or all of the premium.

This plan is

best for:

delta dental ultrasavings ppo

See a Delta Dental

ppo dentist

Deductible Options – Individual/Family

$25/$75

$50/$150

Individual Annual Maximum

The UltraSavings PPO includes CheckUp Plus™. With CheckUp Plus™, benefits paid for diagnostic and

preventive services do not apply to the individual annual maximum.

$1,000

$750

Diagnostic & Preventive Services

Examinations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays every five years. One-time

application of sealants. Space maintainers as needed.

100%

80%*

Basic Restorative Services – Type 1

Emergency treatment to relieve pain, fillings.

80%*

50%*

Basic Restorative Services – Type 2

Simple extractions.

50%*

40%*

Major Restorative Services

Endodontics and periodontics (root canals and gum-disease treatment), oral surgery, crowns, complete and partial dentures, implants, fixed bridges, repairs and adjustments.

50%*

40%*

Orthodontic Services (Optional)

If the group has 10 or more enrolled employees, it may

choose to include orthodontic coverage. Coverage applies

for dependent children to age 19. Orthodontic coverage is not available for groups under 10.

50%*

50%*

Lifetime Orthodontic Maximum

$1,000

$750

Evidence-Based Integrated Care Plan (EBICP)

Delta Dental's Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases and medical conditions that have oral-health implications. These benefits address the unique oral-health challenges faced

by persons with these conditions, and can play an important role in the management of an individual's medical condition.

Included

Included

Dependent Age Limitation

Dependents covered to age 26, except as noted

for orthodontics

Dependents covered to age 26, except as noted

for orthodontics

Vision-Care Discount Program Included

See page 20 for details.

Included

Included

*Deductible applies.

Delta Dental UltraSavings PPO

Delta Dental UltraSavings PPO

*Delta Dental PPO network measured by locations. | †As the standard UltraSavings PPO plan.

PPO savings really

stack up!

See a Delta Dental Premier or Any Other

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12 |Page 13 |Page

The Delta Dental Savings PPO leverages the power of the state’s largest dental PPO network*, combining

a full in-network benefit with cost savings and

treatment guarantees if you see one of the 90 percent of state dentists in the Delta Dental Premier network.

what is a savings ppo?

A savings PPO offers an in-network benefit that’s better than the out-of-network benefit, encouraging

you to see a Delta Dental PPO dentist.

what else is included?

Each Delta Dental Savings PPO includes:

CheckUp Plus™:

Diagnostic and preventive services don’t count against your annual maximum with CheckUp Plus™.

Evidence-Based Integrated Care Plan (EBICP):

The industry-leading benefit enhancement for

whole-body health, EBICP covers additional cleanings for pregnant women, diabetics, and people with other health conditions. See www.deltadentalwi.com/EBICP for more information.

mac plan option

In addition to your choice of annual maximum and deductible, a MAC (Maximum Allowable Charge) plan option is available, but not required. With a MAC plan, members pay a lower rate, but out-of-pocket expenses can be higher when they see a dentist other than a Delta Dental PPO dentist.

what plans are similarly priced?

For roughly the same price† you can choose:

A Delta Dental Passive PPO with a lower annual maximum and/or a higher deductible.

(See page 14)

who is the savings ppo plan for?

Groups looking for immediate and long-term savings. Groups located in areas

where there are a lot of Delta Dental PPO dentists.

Groups where employees pay some or all of the premium. This plan is best for: *Deductible applies.

See a Delta Dental

ppo dentist

See a Delta Dental Premier or Any Other

Dentist

Deductible Options – Individual/Family

$25/$75

$50/$150

$75/$225

$25/$75 $50/$150 $75/$225

Individual Annual Maximum

The Savings PPO includes CheckUp Plus™. With CheckUp Plus™, benefits paid for diagnostic and preventive services

do not apply to the individual annual maximum.

$1,000

$1,500

$2,000

$1,000 $1,500 $2,000

Diagnostic & Preventive Services

Examinations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays once every five years. One-time

application of sealants. Space maintainers as needed.

100%

100%

Basic Restorative Services

Emergency treatment to relieve pain, fillings; simple

extractions.

80%*

60%*

Major Restorative Services

Endodontics and periodontics (root canals and gum-disease treatment), oral surgery, crowns, complete and partial dentures, implants, fixed bridges, repairs and adjustments.

Note: Groups may upgrade oral surgery, endodontic and periodontic coverage to the basic-restorative-services level.

50%*

50%*

Orthodontic Services (Optional)

If the group has 10 or more enrolled employees, it may

choose to include orthodontic coverage. Coverage applies

for dependent children to age 19. Orthodontic coverage is not available for groups under 10.

50%*

50%*

Lifetime Orthodontic Maximum

$1,000

$1,500

$2,000

$1,000 $1,500 $2,000

Evidence-Based Integrated Care Plan (EBICP)

Delta Dental's Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases

and medical conditions that have oral-health implications.

These benefits address the unique oral-health challenges

faced by persons with these conditions, and can play an important role in the management of an individual's medical condition.

Included

Included

Dependent Age Limitation

Dependents covered to age 26, except as noted

for orthodontics

Dependents covered to age 26, except as noted

for orthodontics

Vision-Care Discount Program Included

See page 20 for details.

Included

Included

delta dental savings ppo

Delta Dental Savings PPO

An affordable plan that leverages Delta Dental’s huge PPO network.

Delta Dental Savings PPO

*Delta Dental PPO network measured by locations. | †As a standard $1,000 annual maximum, $50 deductible plan.

Some plans are a dime

a dozen... not ours!

(8)

14 |Page 15 |Page

Delta Dental Passive PPO

Delta Dental’s Premier Plus PPO is the only passive PPO available in Wisconsin that combines the state’s largest dentist network* with cost savings and

treatment guarantees if you see one of the 90% of state dentists in the Delta Dental Premier network.

what is a passive ppo?

A passive PPO offers the same annual maximum, deductibles and coinsurance whether you see a Delta Dental PPO dentist, a Delta Dental Premier dentist, or a non-network dentist.

what else is included?

Each Delta Dental Passive PPO includes:

CheckUp Plus™:

Diagnostic and preventive services don’t count against your annual maximum with CheckUp Plus™.

Evidence-Based Integrated Care Plan (EBICP):

The industry-leading benefit enhancement for

whole-body health, EBICP covers additional cleanings for pregnant women, diabetics, and people with other health conditions. See www.deltadentalwi.com/EBICP for more information.

mac plan option

In addition to your choice of annual maximum and deductible, a MAC (Maximum Allowable Charge) plan option is available, but not required. With a MAC plan, members pay a lower rate, but out-of-pocket expenses can be higher when they see a dentist other than a Delta Dental PPO dentist.

what plans are similarly priced?

For roughly the same price† you can choose:

A Delta Dental Savings PPO with a higher annual maximum and/or a lower deductible (See page 12); or A Delta Dental Enhanced PPO with a lower annual maximum and/or a higher deductible. (See page 16)

who is the passive ppo plan for?

Groups looking to maximize dentist choice without penalties for seeing out-of-network dentists.

Groups located in areas where there are not a lot of Delta Dental PPO dentists.

Groups with employees scattered around the state or country. This plan is best for: *Deductible applies.

delta dental premier plus ppo

(Passive PPO)

See a Delta Dental Premier or Any Other

Dentist

Deductible Options – Individual/Family

$25/$75

$50/$150

$75/$225

$25/$75 $50/$150 $75/$225

Individual Annual Maximum

The Passive PPO includes CheckUp Plus™. With CheckUp Plus™, benefits paid for diagnostic and preventive services

do not apply to the individual annual maximum.

$1,000

$1,500

$2,000

$1,000 $1,500 $2,000

Diagnostic & Preventive Services

Examinations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays once every five years. One-time

application of sealants. Space maintainers as needed.

100%

100%

Basic Restorative Services

Emergency treatment to relieve pain, fillings; simple

extractions.

80%*

80%*

Major Restorative Services

Endodontics and periodontics (root canals and gum-disease treatment), oral surgery, crowns, complete and partial dentures, implants, fixed bridges, repairs and adjustments.

Note: Groups may upgrade oral surgery, endodontic and periodontic coverage to the basic-restorative-services level.

50%*

50%*

Orthodontic Services (Optional)

If the group has 10 or more enrolled employees, it may

choose to include orthodontic coverage. Coverage applies

for dependent children to age 19. Orthodontic coverage is not available for groups under 10.

50%*

50%*

Lifetime Orthodontic Maximum

$1,000

$1,500

$2,000

$1,000 $1,500 $2,000

Evidence-Based Integrated Care Plan (EBICP)

Delta Dental's Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases

and medical conditions that have oral-health implications.

These benefits address the unique oral-health challenges

faced by persons with these conditions, and can play an important role in the management of an individual's medical condition.

Included

Included

Dependent Age Limitation

Dependents covered to age 26, except as noted

for orthodontics

Dependents covered to age 26, except as noted

for orthodontics

Vision-Care Discount Program Included

See page 20 for details.

Included

Included

Delta Dental Passive PPO

The gold standard of small-group plans.

See a Delta Dental

ppo dentist

*Delta Dental PPO network measured by locations. | †As a standard $1,000 annual maximum, $50 deductible plan.

Worth its weight

in gold! Our most

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16 |Page 17 |Page

Delta Dental Enhanced PPO

who is the enhanced ppo plan for?

Groups looking to reward employees for seeing Delta Dental PPO dentists. Groups located in areas

where there are a lot of Delta Dental PPO dentists. This

plan is best

for:

delta dental enhanced ppo

See a Delta Dental

Premier or Any Other Dentist

Deductible Options – Individual/Family

$25/$75

$50/$150

$75/$225

$25/$75 $50/$150 $75/$225

Individual Annual Maximum

The Enhanced PPO includes CheckUp Plus™. With CheckUp Plus™, benefits paid for diagnostic and preventive

services do not apply to the individual annual maximum.

$1,000

$1,500

$2,000

$1,000 $1,500 $2,000

Diagnostic & Preventive Services

Examinations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays once every five years. One-time

application of sealants. Space maintainers as needed.

100%

100%

Basic Restorative Services

Emergency treatment to relieve pain, fillings; simple

extractions.

90%*

80%*

Major Restorative Services

Endodontics and periodontics (root canals and gum-disease treatment), oral surgery, crowns, complete and partial dentures, implants, fixed bridges, repairs and adjustments.

Note: Groups may upgrade oral surgery, endodontic and periodontic coverage to the basic-restorative-services level.

60%*

50%*

Orthodontic Services (Optional)

If the group has 10 or more enrolled employees, it may

choose to include orthodontic coverage. Coverage applies

for dependent children to age 19. Orthodontic coverage is not available for groups under 10.

50%*

50%*

Lifetime Orthodontic Maximum

$1,000

$1,500

$2,000

$1,000 $1,500 $2,000

Evidence-Based Integrated Care Plan (EBICP)

Delta Dental's Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases and medical conditions that have oral-health implications. These benefits address the unique oral-health challenges faced by

persons with these conditions, and can play an important role in the management of an individual's

medical condition.

Included

Included

Dependent Age Limitation age 26, except as noted Dependents covered to for orthodontics

Dependents covered to age 26, except as noted

for orthodontics

Vision-Care Discount Program Included

See page 20 for details.

Included

Included

*Deductible applies.

Delta Dental Enhanced PPO

A plan that puts the power of the PPO to work.

*Delta Dental PPO network measured by locations. | †As a standard $1,000 annual maximum, $50 deductible plan.

Looking for a better benefit? Delta Dental’s Enhanced PPO delivers top-of-the-line benefits when you see a

PPO provider from the state’s largest dentist network*.

what is an enhanced ppo?

An enhanced PPO offers a higher benefit when you

see a Delta Dental PPO dentist and a standard

benefit when you see a Delta Dental Premier dentist

or a non-network dentist.

what else is included?

Each Delta Dental Enhanced PPO includes:

CheckUp Plus™:

Diagnostic and preventive services don’t count against your annual maximum with CheckUp Plus™.

Evidence-Based Integrated Care Plan (EBICP):

The industry-leading benefit enhancement for

whole-body health, EBICP covers additional cleanings for pregnant women, diabetics, and people with other health conditions. See www.deltadentalwi.com/EBICP for more information.

mac plan option

In addition to your choice of annual maximum and deductible, a MAC (Maximum Allowable Charge) plan option is available, but not required. With a MAC plan, members pay a lower rate, but out-of-pocket expenses can be higher when they see a dentist other than a Delta Dental PPO dentist.

what plans are similarly priced?

For roughly the same price† you can choose:

A Delta Dental Passive PPO with a higher annual maximum and/or a lower deductible.

(See page 14)

See a Delta Dental

ppo dentist

Higher in-network coinsurance

keeps money in your wallet.

(10)

18 |Page 19 |Page

Delta Dental 2-4

Premier Plus PPO

Delta Dental 2-4

Advantage PPO

See a Delta Dental PPO Dentist See a Delta Dental Premier or Any Other Dentist See a Delta Dental PPO Dentist See a Delta Dental Premier or Any Other Dentist

Deductible Options – Individual/Family $50/$150 $25/$75 $50/$150

Individual Annual Maximum

Delta Dental 2-4 plans include CheckUp Plus™. With CheckUp Plus™, benefits paid for diagnostic and

preventive services do not apply to the individual annual maximum.

$1,000 $1,000

Diagnostic & Preventive Services

Examinations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays once every five years. One-time

application of sealants. Space maintainers as needed.

100%* 100%* 100% 80%*

Basic Restorative Services

Emergency treatment to relieve pain, fillings. 80%* 80%* 80%* 70%*

Major Restorative Services

Endodontics and periodontics (root canals and gum-disease treatment), extractions and oral surgery, crowns, complete and partial dentures, implants, fixed bridges, repairs and

adjustments.

50%* 50%* 50%* 40%*

Orthodontic Services Not Covered Not Covered

Evidence-Based Integrated Care Plan (EBICP)

Delta Dental's Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases

and medical conditions that have oral-health implications.

These benefits address the unique oral-health challenges

faced by persons with these conditions, and can play an important role in the management of an individual's medical condition.

Included Included

Dependent Age Limitation age 26, except as noted for Dependents covered to orthodontics

Dependents covered to age 26, except as noted

for orthodontics

Vision-Care Discount Program Included

See page 20 for details. Included Included

2-4-enrolled dental plans

*Deductible applies.

2-4-Enrolled Delta Dental Plans

We understand the need to watch every penny.

Delta Dental has great dental-benefits options for

Wisconsin’s smallest groups. Choose a PPO plan that rewards employers for using Delta Dental’s sizable

PPO network, or choose a plan with the same benefits

in- and out-of-network. You get Delta Dental’s award-winning customer service no matter which plan you choose.

what else is included?

Each Delta Dental 2-4-Enrolled plan includes:

CheckUp Plus™:

Diagnostic and preventive services don’t count against your annual maximum with CheckUp Plus™.

Evidence-Based Integrated Care Plan (EBICP):

The industry-leading benefit enhancement for

whole-body health, EBICP covers additional cleanings for pregnant women, diabetics, and people with other health conditions. See www.deltadentalwi.com/EBICP for more information.

waiting periods

For groups with an existing dental plan, there are no waiting periods for those enrolling during the initial enrollment period.

Waiting periods apply for groups with no existing dental plan, and for enrollees who waive coverage initially, drop coverage, or who become eligible for the plan after the initial enrollment period (new hires or qualifying events). There is a six-month waiting period for endodontics (root canals), periodontics (gum-disease treatment), extractions, and oral surgery, and a 12-month waiting period for crowns,

implants, complete and partial dentures, fixed

bridges, and repairs and adjustments. There is no

benefit waiting period for diagnostic and preventive

services, or basic restorative services.

2-4-Enrolled Delta Dental Plans

The harder you look,

the better we look.

(11)

20 |Page 21 |Page

Vision Discount Program

Vision Discount Program

Member Benefit

Exam with Dilation as Necessary exam/$10 off contact-lens $5 off comprehensive exam

Complete Pair Glasses Purchased

The following discounts and fees for frames, lenses and lens options apply only if a complete

pair is purchased in the same transaction. Items purchased separately will be discounted 20% off of the retail price.

Frames: Any frame available at provider location 30% off retail price

Single Plastic Lenses Including Standard Scratch Coating Single-Vision Bifocal Trifocal Member Pays $75 $95 $125 Lens Option UV Coating

Tint (solid and gradient)

Standard Polycarbonate

Standard Anti-Reflective Coating Standard Progressive (add-on to bifocal)

Member Pays $15 $15 $40 $45 $70

Conventional Contact Lenses: Applied to materials only 15% off retail price

Laser Vision Correction: LASIK or PRK 15% off retail price or 5% off promotional price

Frequency: Exams, frames, lenses, and contact lenses Unlimited

vision discount program

Great savings that are easy to see.

Delta Dental of Wisconsin small-group plans come

with a money-saving Vision Care Discount Program

at no additional cost.

Through our partnership with EyeMed Vision Care®, members save on eyewear, contacts, exams, even

laser vision correction. EyeMed serves more than

140 million people and has a vast network of vision

providers. Best of all, there’s no limit to the number

of times you can use your vision discount.

the discount program features:

• Overall savings up to 35 percent

• Access to thousands of private practice and retail providers nationwide, including LensCrafters®, Target Optical®, Sears Optical®, Shopko® Optical and Pearle Vision®

• Choice of any product, including designer frames • Savings on laser vision correction

• Replacement contact lenses by mail

additional Notes:

• Replacement contact lenses may be

obtained online. Details are available at www.eyemedvisioncare.com/deltadental

• Members receive a 20 percent discount on

items not included under the program, when these items are purchased at participating providers

• Retail prices may vary by location

program exclusions:

• Orthoptic or vision training, subnormal vision aids,

and associated supplemental testing

• Medical and/or surgical treatment of the eye, eyes,

or supporting structures

• Corrective and safety eyewear

• Services provided as a result of any workers’

compensation law

• Plano nonprescription lenses and nonprescription sunglasses (20 percent discount)

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22 |Page 23 |Page

Accounting, Auditing, & Bookkeeping Advertising

Agricultural Production – Crops Agricultural Production – Livestock & Animal Specialties

Attorneys & Legal Services Automotive Dealers, New & Used Beauty/Barber Shops

Boat Dealers Bowling Alleys

Business & Professional Organizations Churches

Dentists’ Offices Eating & Drinking Places

Engineering & Architectural Services Exchanges, & Services

Gas Stations, Convenience Stores Highway Passenger Transportation Holding & Other Investment Offices

Home Healthcare

Hospitals, Medical & Dental Labs Hotels, Motels, Campgrounds Insurance Agents, Brokers, & Service Insurance Carriers

Labor, Political, Civic & Social Organizations Local & Suburban Transit & Interurban Management & Public Relations Medical Service & Health Insurance Mobile-Home Dealers

Motorcycle Dealers Movie Theaters

Personal Services

Physician, Other Healthcare Offices Real Estate Brokers

Recreation & Utility-Trailer Dealers Research & Testing Services

Schools, Including Colleges & Universities Security & Commodity Brokers, Dealers, Subdividers & Developers

Transportation Services Travel Agents/Tour Operators Unclassified Health Services

Unclassified Membership Organizations Unclassified Services

Exclusions

Delta Dental small-group plans do not cover the following

(see group contract or handbooks for definitions of terms used in this section):

1. Dental procedures provided or commenced prior to the effective date of the subscriber’s or covered dependent’s coverage under this contract.

2. Dental procedures to treat injuries or conditions com-pensable under workers’ compensation or employers’ liability laws.

3. Prescription drugs and pre-medications. 4. Preventive control programs.

5. Charges for completion of forms. 6. Charges for consultation.

7. Charges by any hospital or other surgical or treatment facility, or any additional fees charged by a dentist for treatment in any such facility.

8. Charges for treatment of, or services related to, temporomandibular joint dysfunction.

9. Services that are determined to be partially or wholly cosmetic in nature.

10. Cast restorations placed on covered dependents under age 12.

11. Prosthetics placed on covered dependents under age 16. 12. Appliances, restorations, or procedures for:

(a) increasing vertical dimension; (b) restoring occlusion;

(c) correcting harmful habits; (d) replacing tooth structure lost by attrition; (e) correcting congenital or developmental malformations except in newly born children; (f) temporary dental procedures; (g) splints, unless necessary as a result of accidental injury.

13. Dental procedures provided by other than a dentist or licensed hygienist employed by a dentist.

14. Dental procedures to treat injuries or diseases caused by riots or any form of civil disobedience.

15. Dental procedures to treat injuries sustained while committing a criminal act.

16. Dental procedures to treat injuries intentionally inflicted. 17. Replacement of lost or stolen dentures or charges for duplicate dentures.

18. Dental procedures in cases for which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained.

19. Local anesthetic is covered as a part of a dental procedure. General anesthetic or intravenous sedation is a benefit only when billed with covered oral surgery (cutting procedures).

20. Procedures not specifically covered under this contract. 21. If orthodontic procedures are included as benefits under your group’s contract, the repair and replacement of orthodontic appliances are not covered.

Limitations

Coverage for some services under the plan is subject to frequency and age limitations. These limitations and restrictions are described in the handbook and group contract. Copies of these materials are available by calling Delta Dental of Wisconsin at 800-236-3713.

Requirements and considerations

for all delta dental small-group plans

• The plan must be sponsored by the employer. The employer

will collect premiums via payroll deduction.

• A clear employer-employee relationship must exist. • Employment must be full-time, year-round and not experience seasonal layoffs.

• The business has not been cancelled by another dental carrier within the past 36 months.

• Benefit accumulation period is calendar year.

• Subscribers may use the national Delta Dental Premier and Delta Dental PPO dentist networks.

• Retirees are not eligible unless all active employees are eligible for the plan.

• In order to enroll dependents, the employee must be enrolled.

• Only group-billing format is available; no individual billings can be accommodated. Individual COBRA billings are not available.

• The patient’s coinsurance is based on the applicable percentage of the dentist’s billed fee or the maximum plan allowance, whichever is less.

• All contracted services are available to the employee upon the date of eligibility. Note: Benefit waiting periods may apply.

• For groups with open enrollment, an employee who waived coverage or dropped coverage may enroll only during the open enrollment period. Waiting periods may apply.

Stevens Point Office P.O. Box 828

Stevens Point, WI 54481 800-236-3713 (toll-free) Fax 715-343-7623

Milwaukee Office 1233 North Mayfair Road Suite 204 Milwaukee, WI 53226 888-456-2711 (toll-free) Fax 414-607-6088 Madison Office 725 Heartland Trail Suite 205 Madison, WI 53717 877-577-7449 (toll-free) Fax 608-831-9384 • Participation is based on enrollment of all eligible employees except

those who submit waiver cards indicating that they have coverage under their spouse’s plan. Waiver forms are required for all employer-contributory plans.

• Delta Dental small-group plans include coverage for teeth lost prior to the effective date, and pre-existing conditions.

• A Delta Dental small-group plan must be the only dental plan offered. • Rates are guaranteed for one year from the effective date of coverage.

for delta dental table of allowances and 2-4-enrolled

plans only

• The total number of eligible employees and dependents participating

must be equal to or greater than the percentage of the employer contribution. Example: With an employer contribution of 75%, a minimum of 75% of eligible employees must participate.

special requirements for premier plus ppo, enhanced

ppo, savings ppo and ultrasavings ppo plans

• Delta Dental small-group plans are open to groups with 5-49 enrolled

employees.

• Orthodontic coverage is available only to groups of 10 or more enrolled employees.

• If orthodontic coverage is purchased, all families must accept the orthodontic benefit with the same maximum.

special requirements for 2-4 plans

• 2-4 Premier Plus PPO and 2-4 Advantage PPO are open to groups

with 2-4 enrolled employees.

• Two-person groups may not consist of enrollees residing at the same address.

• A company wage and tax statement must accompany the group application.

rate adjustments

The types of businesses listed at right are eligible for the program if they meet other underwriting guidelines, but require an 18 percent adjustment on the standard rates. This list is not all-inclusive. If you are uncertain about the industry type and whether a rate adjustment would apply, contact the sales department. See below for complete contact information.

Underwriting Guidelines

Underwriting Guidelines

Group acceptance is not guaranteed. Approval of coverage is

contingent upon underwriting acceptance.

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Figure

Table of Allowances plan rates tend to stay the same.

References

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