OCC DENTAL INSURANCE PROGRAM

OCC DENTAL INSURANCE PROGRAM
A GUIDE TO YOUR DENTAL BENEFITS
deltadentalins.com/OCC
A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION
DENTAL COVERAGE
TO SMILE ABOUT.
Delta Dental has been providing dental
benefits for nearly 60 years.
• Two available dental plan options from
which to choose:
Starting January 1, 2015, you and your eligible
family members can join millions of others
nationally who trust their smiles to Delta
Dental. The OCC Dental Insurance Program will
provide employees and retirees of the Office of
the Comptroller of the Currency and employees
of the Office of Financial Research with:
o PPO — for active employees and OCC
retirees
• Quality, cost-effective dental coverage
o DHMO — for active employees and OCC
employees who retire on disability
• A nationwide network of contracted dentists
for both plans
• Confidence that your dental health is our
priority
THE OCC DENTAL INSURANCE PROGRAM
OFFERS YOU CHOICES.
Compare the benefits under each option.
As an employee, the OCC Dental Insurance
Program offers you the choice of two quality
dental options — the PPO option, called Delta
Dental PPOSM plan and the dental HMO –
DHMO option, known as DeltaCare® USA plan.
Each option is structured differently:
• PPO – The PPO plan has a network of
preferred providers and you can visit any
licensed dentist for treatment. The plan
provides for both in and out-of-network
benefits; however you will usually receive
the greatest benefit when you visit a
participating in-network dentist. If you
are covered by other dental insurance,
coordination of benefits is applicable. One
very important requirement is that any
dental coverage you may have under either
of the federal benefit programs (Federal
Employees Health Benefits [FEHB] or Federal
Employees Dental and Vision Insurance
Program [FEDVIP]) is the primary payer to
any benefits payable under this program.
• DHMO – The DeltaCare USA plan, in most
states, operates through a network of
participating dentists that manage all
of your dental care. You will be required
to select a primary care dentist or one
may be assigned to you.* You pay a
fixed copayment for services, and except
for emergencies, there is generally no
coverage for out-of-network benefits. If
you are covered by other dental insurance,
coordination of benefits does not apply.
The PPO and DeltaCare USA plans each
provide a wide range of preventive, diagnostic,
basic and major restorative services as well
as orthodontia. Although not required, those
enrolled in the PPO plan are encouraged to
ask their dentist to obtain a predetermination
of benefits from Delta Dental before having
any major restorative and prosthodontic
services performed. Obtaining a
predetermination will help you avoid any
surprises regarding your out-of-pocket costs.
The chart on the following page provides an
overview of both options through Delta Dental
so that you can compare the benefits.
*DeltaCare USA is not available in MN and ND. In AK, CT, LA, ME, MS, MT, NH, NC, OK, SD, VT and WY, DeltaCare USA is
provided as an open access plan. Enrollees can obtain treatment from any licensed dentist and do not need to select a
dentist upon enrolling in the plan. Because enrollees can visit any dentist, no specialty care authorization is needed.
Deductibles and maximums may apply for services provided by an out-of-network dentist.
Plan Features
PPO
In-Network
PPO
Out-of-Network
DeltaCare USA
(DHMO)
Plan Pays
You Pay
Plan Pays
You Pay
Class I – Diagnostic and Preventive
(exams, x-rays, cleanings)
100%
0%
100%
0%
No Cost
Class II – Basic Restorative (fillings, root
canals, simple extractions)
80%*
20%*
80%*
20%*
Copayments range from
$0 — $200
Class III – Major Restorative Care
(crowns, wisdom teeth extractions,
partials, dentures, implants)
Class IV – Orthodontia
60%*
40%*
60%*
40%*
60%*
40%*
60%*
40%*
Preauthorization is
not required
Preauthorization is
not required
$50 per person
$150 per family
$50 per person
$150 per family
$2,500
$2,500
$2,000 for adults
and children
$2,000 for adults
and children
No lifetime orthodontic
maximum
Delta Dental
network dentists
file claim forms and
accept payment
directly from Delta
Dental
Non-Delta Dental
dentists may
require payment
upfront and may
require you to file
your own claim for
reimbursement
No claim forms
Pay the listed
copayment for covered
services at the time of
your visit
Authorization for specialty care
treatment
Annual Deductible
Annual Maximum (Class I, II and III
services)
Orthodontic Lifetime Maximum
Claims
Copayments range from
$170 — $450
Optional treatment:
limited to implant/
abutment supported
crowns and dentures
Copayments range from
$1,150— $2,100
Your DeltaCare USA
(DHMO) dentist
will coordinate
authorization for
specialty care
treatment†
No annual deductible
No annual maximum
*Subject to annual deductible
†If a DeltaCare USA provider determines that a patient requires services from a specialist and there is no DeltaCare USA specialist
within the lesser of 35 miles or one hour commuting time, the patient will be authorized to seek treatment from a PPO, Premier or
non-network specialist.
An explanation of PPO exclusions and limitations is available online at deltadentalins.com/OCC.
COMPARE THE DENTIST NETWORKS
AVAILABLE TO YOU.
Seeing a Delta Dental PPO network dentist for your covered dental care can save you money!
You can visit any licensed dentist under the Delta Dental PPO plan, but you’ll maximize plan value
by taking advantage of our large PPO network because these dentists have agreed to reduced
contracted rates. The Delta Dental Premier® network also provides cost protections for PPO
enrollees. Premier dentists’ contracted fees are typically higher than PPO dentists’ fees, but they
can usually help you save on out-of-pocket costs. Both PPO and Premier dentists will not “balance
bill” you for additional fees, unbundle services, or require pre-payment for services. You are only
responsible for any applicable deductibles, coinsurance, charges for non-covered services and
amounts over plan maximums.
For services provided by a Delta Dental PPO or Delta Dental Premier dentist, Delta Dental will
reimburse the dentist directly according to a negotiated rate. For services provided by an out-ofnetwork dentist, Delta Dental will reimburse the enrollee based upon maximum contract allowances
but the dentist may bill the enrollee up to their normal fees.
A list of Delta Dental PPO and Delta Dental Premier dentists is available at deltadentalins.com/OCC. The
examples in the chart below depict your typical savings when you visit a Delta Dental PPO network
dentist versus a Delta Dental Premier dentist or a non-contracted dentist.
The chart below depicts an example of savings you may expect when visiting a Delta Dental PPO
network dentist or a Delta Dental Premier dentist as compared to the cost of treatment from a noncontracted dentist. These are hypothetical numbers for illustrative purposes only and assumes that
no maximum or deductibles apply.
Delta Dental
PPO Dentist
Delta Dental
Premier Dentist
Non-Delta Dental
Dentists*
$1,000
$1,000
$1,000
Contract allowance (amount on which
Delta Dental bases it payment)
$640
$800
$900
Coinsurance (% of contract allowance
Delta Dental will pay)
50%
50%
50%
Delta Dental’s share
$320
$400
$450
Enrollee’s share
$320
$400
$550
$0
$0
$100
Example
Dentist’s charge for a crown
Balance billing (any amount over
the contract allowance that the
enrollee is paying)
* Non-contracted dentists may charge enrollees the difference between their usual fee and Delta Dental’s reimbursement up
to their full fee.
DeltaCare USA (DHMO) network dentists make it simple to obtain affordable dental care.
Your DeltaCare USA (DHMO) plan under the OCC Dental Insurance Program is easy to use and offers
you a combination of quality and affordability. The plan is designed to encourage you and your family
to visit the dentist regularly to maintain your dental health.
Once you have selected your DeltaCare USA (DHMO) primary dentist, you must visit that dentist
in order to receive your benefits.* General dentists manage their patients’ comprehensive dental
needs, including referrals to specialists, when needed. Having a primary dentist allows you to enjoy
a long-term relationship with the same dentist throughout your enrollment. With no deductibles,
modest copayments and no claim forms to fill out, you can start saving on out-of-pocket costs
immediately. And with no annual maximum limitations, you can use your DeltaCare USA (DHMO)
benefits all year long.
* In AK, CT, LA, ME, MS, MT, NH, NC, OK, SD, VT and WY, DeltaCare USA is provided as an open access plan. Enrollees can
obtain treatment from any licensed dentist and do not need to select a dentist upon enrolling in the plan. Because enrollees
can visit any dentist, no specialty care authorization is needed. Deductibles and maximums may apply for services provided
by an out-of-network dentist.
ENROLLING IN THE
OCC DENTAL INSURANCE PROGRAM IS EASY!
Paying the premiums for your coverage.
Your employer pays 100% of the premiums for you and your eligible dependents – regardless of the
dental option you chose. When an OCC employee who has been participating in the program retires,
he or she can continue dental coverage by electing the PPO option.
Retirees who choose to participate in the PPO option must pay their own monthly premiums through
electronic funds transfer or through recurring credit card payment. The monthly premium rates for
retiree dental coverage are as shown below:
OCC Retirees – Monthly PPO Premium Rates Effective January 1, 2015
Single (retiree only)
$ 47.38
Two person (retiree and one dependent)
$ 85.64
Family (retiree and two or more dependents)
$155.02
Consult with your Human Resources benefits administrator regarding enrollment.
If you are a newly hired employee, your Human Resources benefits administrator will assist you with
enrolling in the program. Retiring OCC employees who were participating in the program as an active
employee are provided a one-time opportunity to elect the PPO option as a retiree. Retirees can self-enroll
online through the website portal at deltadentalins.com/OCC. At the time of enrolling in the program as a
retiree, a two-month premium prepayment will be required. You will also need to complete an Electronic
Funds Transfer (EFT)/Recurring Credit Card Payment (RCCP) Authorization form, available on the
website, to set up your recurring premium payments; mail or fax the completed form to Delta Dental
at the address shown on the form.
DELTA DENTAL’S
SMILEWAY® WELLNESS PROGRAM.
More than just great coverage to help you
maintain your smile.
Preventive dental care is the number one way
to keep your smile healthy. Our SmileWay®
Wellness Program is your one-stop shop for
oral health-related tools, tips and resources for
smiles of all ages.
Take the SmileWay Wellness Challenge!
The SmileWay Wellness Challenge provides
recommendations for how to participate in
the program by taking advantage of the
extensive resources available on our
SmileWay Wellness site.
• Stay informed
Receive regular dental health tips and
information by:
– Subscribing to the Grin! Newsletter – a
free resource emailed to you quarterly with
articles, tips and tools to help you take
great care of your smile.
– Connecting with us on Facebook and
Twitter – articles and tips posted weekly
about oral and physical health care.
All of this is accessible from our SmileWay
Wellness site at deltadentalins.com/occ
Be sure and bookmark the page so you can
refer to it frequently!
• Review your habits
Meet the Smyles – Just for Kids!
Take one or both of our interactive quizzes
to see if you are at risk for cavities or gum
(periodontal) disease. When you receive
your quiz results, you can sign up to receive
customized emails based on your risk level.
Kids can meet the Smyles family and get dental
health tips, games, stories and more created just
for them!
• Get educated
Read any of the 100+ articles on dental
health-related topics, including the
mouth-body connection, preventive and
emergency care, oral health for seniors,
dental treatments and conditions,
and nutrition.
DELTA DENTAL’S WEBSITE IS JUST FOR YOU.
DELTADENTALINS.COM/OCC
GIVES YOU WHAT YOU NEED,
WHENEVER YOU NEED IT.
Delta Dental has designed a website specifically for the OCC Dental Insurance Program to help you with your program needs.
At deltadentalins.com/OCC, you can search for a network dentist online as well as access program resources such as a list of
Frequently Asked Questions and your new OCC plan benefits booklet. Register to “Manage Your Account” and access self-service
tools to view and print enrollment cards, view your PPO claims status and electronic Explanation of Benefits statements, and
more – all while enjoying enhanced, state-of-the-art security of your personal information, 24 hours a day, seven days a week! If
you do not have website access or want to contact Delta Dental by telephone, call 844-883-4288 for assistance.
The Delta Dental PPO plan is underwritten by Delta Dental Insurance Company.
The DeltaCare® USA plan 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, NC, NH, OK, OR, RI, SC, SD, VT, WA, WI, WY — Dentegra Insurance Company; AK, CT, DC, DE, FL,
GA, KS, LA, MS, MT, TN and WV — 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, Inc.; PA — Delta Dental
of Pennsylvania; VA – Delta Dental of Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These
companies are financially responsible for their own products.
A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION
OCC Brochure #81536 11/14

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