Delta Dental of Oklahoma - Select Last Printed: May …...Please mail new group submissions to:...

Delta Dental of Oklahoma - Select

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Last Printed: May 2016

Application Checklist for New Groups When enrolling in a new group, there are several key areas essential in providing a smooth implementation to Delta Dental. In order to better serve our brokers and clients, we have developed a checklist to aid in the process of enrolling and setting up new groups with Delta Dental. Application for Group Contract completed in its entirety and signed by the person authorized to contract for the group. Individual enrollment form completed and signed by each employee enrolling in the dental plan; enrollment may also be submitted by electronic file. For more information on acceptable electronic file formats, please contact [email protected]. If electing Federally Compliant Plan/Plans: Federally Compliant Plan Application for Group Contract completed in its entirety and signed by the person authorized to contract for the group. Federally Compliant Plan Individual enrollment form completed and signed by each employee enrolling in the Federally Compliant dental plan; enrollment may also be submitted by electronic file. For more information on acceptable electronic file formats, please contact [email protected]. The placement of your group with Delta Dental of Oklahoma is important to us and very much appreciated. If you have any questions, please feel free to call us at 405‐607‐4709 (OKC Metro) or 866‐685‐2112 (Toll Free) or email us at [email protected]. Please mail new group submissions to: Delta Dental of Oklahoma Attention: Sales P.O. Box 54709 Oklahoma City, Oklahoma 73154‐1709 or send an email to: [email protected]

Checklist for New Groups

Number of Eligible Employees: 2‐99† Proposed Effective Date: January – December 2016 (1st day of selected month)

Delta Dental of Oklahoma – Select for employer groups is a unique approach to providing solutions to the ever changing needs of employees. With Delta Dental – Select, employers can provide their employees the opportunity to select from the menu of plans listed below.

Plan Options:

Delta Dental Patient Direct

Discount Program

Delta Dental PPO

Delta Dental PPO – Plus Premier

Delta Dental PPO – Plus Premier “Elite”

Federally Compliant Plans for Covered Person(s) to age 19

Only** High Low

Preventive/Diagnostic Services Discount 100% 100% 100% 100% 100% *

Basic Services Discount 80% * 80% * 80% * 80% * 60% *

Major Services Discount 50% * 50% * 50% * 50% * 50% *

Orthodontic Services Discount 50%

Child Only 50%

Child Only 50%

Family

50% Medically

Necessary

50% Medically

Necessary

Per Person Deductible N/A $50 $50 $50 $25 $100

Annual Maximum N/A $1,500

Per Person $1,500

Per Person $3,000

Per Person N/A N/A

Orthodontic Lifetime Maximum N/A $1,500 Per Child

$1,500 Per Child

$2,000 Per Person

N/A N/A

Maximum Out‐of‐Pocket – 1 covered person

N/A N/A N/A N/A $350 $350

Maximum Out‐of‐Pocket – 2 or more covered persons

N/A N/A N/A N/A $700 $700

Additional Benefits Available N/A N/A N/A See Program of Benefits

N/A N/A

† A minimum of two subscribers must be enrolled in either Delta Dental PPO, PPO – Plus Premier and/or PPO – Plus Premier “Elite” plans.

* Per Person Deductible Applies ** Benefits are based on the State Children’s Health Insurance Program (SCHIP) guidelines. Special processing policies/limitations/exclusions will apply for medically necessary procedures. Deductibles and Co‐Insurance will apply to your Maximum Out‐of‐Pocket costs. This is not an insured program. Medically Necessary – Orthodontic treatment and/or services are only covered with orthognathic surgery cases or certain designated syndromes or genetic disorders such as cleft palate. Benefits are only allowed for medically necessary orthodontic services to help correct severe handicapped malocclusions caused by cranio‐facial orthopedic deformities involving teeth.

Monthly Rates: Patient Direct PPO PPO – Plus Premier

PPO – Plus Premier “Elite”

Federally Compliant High Low

Employee Only $5.00 $ 32.00 $ 36.00 $ 63.00 N/A N/A

Employee + Spouse N/A $ 64.00 $ 72.00 $128.00 N/A N/A

Employee + Child(ren) N/A $ 80.00 $ 98.00 $166.00 N/A N/A

Family $7.00 $107.00 $144.00 $237.00 N/A N/A

One Child N/A N/A N/A N/A $30.51 $18.80

Two Children N/A N/A N/A N/A $61.02 $37.60

Three or more children N/A N/A N/A N/A $91.53 $56.40

Delta Dental of Oklahoma ‐ Select

Program of Benefits: Delta Dental PPO

Delta Dental of Oklahoma’s benefits consist of Diagnostic and Preventive Services, Basic Services, Major Services and Orthodontic Services. The benefits listed below are not a complete list. Limitations to benefits can be found in the Summary Plan Description. Diagnostic and Preventive Services (Class I Benefits)

Oral evaluation

Routine prophylaxis, including cleaning and polishing

Bitewing and periapical x‐rays

Full‐mouth x‐rays

Space maintainers for eligible dependent children only

Minor emergency (palliative) treatment for relief of pain

Topical application of fluoride for eligible dependent children only

Topical application of sealants for eligible dependent children only, limited to permanent first and second molars free of caries and restorations on the occlusal surface

Periodontal maintenance Note: Benefits paid by the Plan for covered oral evaluations and routine prophylaxis will not reduce your Benefit Year Maximum Payment for combined Class I, Class II and Class III covered dental services.

Basic Services (Class II Benefits)

Amalgam and composite fillings

Stainless steel crowns for eligible dependent children only when the natural teeth cannot be restored with another filling material

General Anesthesia/IV Sedation – when administered by a properly licensed dentist, in the dental office, in conjunction with covered oral surgery or when necessary due to concurrent medical conditions

Endodontics – includes pulpal therapy and root canal treatment

Oral Surgery – extractions and other covered oral surgery procedures

Periodontics – procedures performed for the treatment of diseases of the gums and supporting structures of the teeth, excluding periodontal maintenance procedures which is payable as a Diagnostic/Preventive Service (Class I)

Major Services (Class III Benefits)

Major Restorative – provides porcelain or cast restorations (other than stainless steel) when teeth cannot be restored with another filling material

Prosthodontics – procedures for construction of fixed bridges, partial dentures and complete dentures

Implants – procedures for implant placement, maintenance and repair of implants, and implant‐supported prosthetics Orthodontics (Class IV Benefits)

The necessary treatment and procedures required for the correction of malposed teeth Orthodontic coverage is a benefit provided for dependent children only to the age of 26.


Program of Benefits: Delta Dental PPO – Plus Premier

Delta Dental of Oklahoma’s benefits consist of Diagnostic and Preventive Services, Basic Services, Major Services and Orthodontic Services. The benefits listed below are not a complete list. Limitations to benefits can be found in the Summary Plan Description. Diagnostic and Preventive Services (Class I Benefits)

Oral evaluation




Space maintainers for eligible dependent children only




Periodontal maintenance Note: Benefits paid by the Plan for covered oral evaluations and routine prophylaxis will not reduce your Benefit Year Maximum Payment for combined Class I, Class II and Class III covered dental services.











Implants – procedures for implant placement, maintenance and repair of implants, and implant‐supported prosthetics

Orthodontics (Class IV Benefits)

The necessary treatment and procedures required for the correction of malposed teeth Orthodontic coverage is a benefit provided for dependent children only to the age of 26.


Program of Benefits: Delta Dental PPO – Plus Premier “Elite”

Delta Dental of Oklahoma’s benefits consist of Diagnostic and Preventive Services, Basic Services, Major Services and Orthodontic Services. The benefits listed below are not a complete list. Limitations to benefits can be found in the Summary Plan Description.

Diagnostic and Preventive Services (Class I Benefits)

Oral evaluation

Routine prophylaxis, including cleaning and polishing and/or Periodontal maintenance (maximum combined total of four)



Space Maintainers for eligible dependent children only




Note: Benefits paid by the Plan for covered oral evaluations and routine prophylaxis will not reduce your Benefit Year Maximum Payment for combined Class I, Class II and Class III covered dental services.








Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth

Non‐intravenous conscious sedation

Inhalation of nitrous oxide/analgesia, anxiolysis




Implants – procedures for implant placement, maintenance and repair of implants, and implant‐supported prosthetics

Other drugs and/or medicaments, by report

Application of desensitizing medicament

Occlusal guard

Repair or reline of the occlusal guard

External bleaching tray – per arch – performed in office Orthodontics (Class IV Benefits)

The necessary treatment and procedures required for the correction of malposed teeth Orthodontic coverage is a benefit provided for the entire family.



Form No. DDOK Select APP.2 July 2014 CONFIDENTIAL

APPLICATION FOR GROUP CONTRACT(Delta Dental Select)

This Application For Group Contract is hereby made a part of the Plan Agreement, and is subject to all terms and conditions of theAgreement thereof. This Application For Group Contract will not be accepted by Delta Dental unless completed in its entirety.

PLAN EFFECTIVE DATE ERISA EXEMPT: Yes No

GROUP NAME GROUP EXECUTIVE

Title

STREET ADDRESS Phone No./Fax. No.

E-Mail Address

MAILING ADDRESS GROUP CONTACT

Phone No./Fax No.

TELEPHONE NO. ( ) E-Mail Address

FACSIMILE NO. ( ) BILLING CONTACT

WEBSITE ADDRESS Phone No./Fax No.

FEDERAL TAX ID NO. E-Mail Address

TYPE OF BUSINESS ELIG. CONTACT

SIC CODE Phone No./Fax No.

E-Mail Address

ELIGIBILITY/ENROLLMENT:

Total Employees: Minus Ineligible = Total Eligible EmployeesExplain Ineligible Employees, e.g., part-time, etc.:Note: Participation requirement of a minimum of two (2) enrolled Eligible Employees.

Employer Monthly Contribution to the Employee Cost of Plan: % or $

Delta Dental PPO - Delta Dental PPO -MONTHLY RATES: Delta Dental PPO Plus Premier Plus Premier – “Elite”

Employee Only $32.00 $36.00 $63.00Employee + Spouse $64.00 $72.00 $128.00Employee + Children $80.00 $98.00 $166.00Employee + Family $107.00 $144.00 $237.00

(Please complete the reverse side of this Application)

For Delta Dental of Oklahoma Use Only:Group No.___________________For group sizes with 2-99 Eligible

Waiting Periods: New Employees: A new employee’s coverage will become effective the first of the month followingsixty (60) days of continuous full-time employment.

Billing Notification: E-Bill (e-mail notice) Facsimile US MailPayment Options: Pay-by-Phone Automatic Draft FastPay™ On-Line Check PaymentFULLY INSURED PLAN OPTIONS: Please check the box of the option(s) you are making available to your employees

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Form No. DDOK Select APP.2 July 2014 CONFIDENTIAL

BENEFITS SUMMARY - Delta Dental PPOCovered Services & Plan Co-payment Percentages: Class I - Diagnostic & Preventive Services ......................................... 100%

Class II - Basic Services.......................................................................... 80%Class III - Major Restorative Services...................................................... 50%Class IV - Orthodontic Services………………....................................... 50%

Maximum Benefit Payment Per Person Per Calendar Year - Classes I, II, and III Services combined.........................................$1,500Maximum Lifetime Benefit Payment Per Eligible Dependent Child - Class IV Services .............................................................$1,500Deductible Per Calendar Year (Classes II and III only)................................................................................................... $50 Per Person

BENEFITS SUMMARY - Delta Dental PPO – Plus PremierCovered Services & Plan Co-payment Percentages: Class I - Diagnostic & Preventive Services ......................................... 100%


Maximum Benefit Payment Per Person Per Calendar Year - Classes I, II, and III Services combined.........................................$1,500Maximum Lifetime Benefit Payment Per Eligible Dependent Child - Class IV Services .............................................................$1,500Deductible Per Calendar Year (Classes II and III only)................................................................................................... $50 Per Person

BENEFITS SUMMARY - Delta Dental PPO - Plus Premier – “Elite”Covered Services & Plan Co-payment Percentages: Class I - Diagnostic & Preventive Services ......................................... 100%


Maximum Benefit Payment Per Person Per Calendar Year - Classes I, II, and III Services combined.........................................$3,000Maximum Lifetime Benefit Payment Per Person - Class IV Services...........................................................................................$2,000

Deductible Per Calendar Year (Classes II and III only)................................................................................................... $50 Per Person

PRODUCER/CONSULTANT INFORMATION: Please complete the information requested below.

Producer/Consultant Social Security No.Agency Federal Tax ID No.Street Address Mailing Address

Business Phone No.( ) Fax No. ( )E-Mail Address Website Address

HOLD HARMLESS

Delta Dental has not reviewed the employer’s request for plan coverage nor designed the group plan to meet any federal requirementsfor Discriminatory Employee Benefit Plans. Said plan may not be in compliance with criteria established for DiscriminatoryEmployee Benefit Plans, and employer holds Delta Dental Plan of Oklahoma harmless if said plan fails to meet any suchrequirements.

All information above is true and correct to I have reviewed the benefits and eligibility requirementsthe best of my knowledge. as stated in this Group Application and accept them.

Producer/Consultant’s Signature Employer’s Authorized Signature

Date Title

DatePlease mark if the following is submitted with this signed application: Enrollment forms

Electronic enrollment dataCheck for first month’s premium

Please ship my new group packet (plan agreement, etc.) to: Producer/Consultant Group Contact

Note: A set of identification cards and a dental Summary Plan Description will be mailed direct to the employee’s home, asindicated in the enrollment form or electronic enrollment data.

Purpose of Authorization (select one) New authorization Changes to existing authorization (Note: Changes will be completed within 30 days from date of receipt) Please print or type when completing this form. Name of Company: Group Number: Address: Phone Number: Fax Number: Name of Depositor:

Group Auto. Draft form, Revised: October 2015

-OR-

Mail this form with a voided check to: Delta Dental of Oklahoma Attn: Finance P.O. Box 54709 Oklahoma City, Oklahoma 73154-1709 * If the 5th of the month falls on a weekend or holiday, Delta Dental of Oklahoma will debit the specified account on the next business day. ** Signature must be that of an authorized signer on the bank account.

Automatic Draft Authorization

(Print name exactly as it appears on Financial Institution records) Name of Financial Institution: Branch: Address: Phone Number:

Type of Account: Checking Savings I (We) hereby authorize Delta Dental of Oklahoma and the financial institution named above to begin deductions of company dental premium from the account I have indicated herein. I understand that company eligibility can be placed on hold for a rejected draft. I also understand that this specified account would be deducted on the 5th day of each month.* Print Name: Signature: ** Date: Note: A voided check must be attached to this authorization to process intended application. Fax this form with a voided check to: 405-241-0680

CR-18, Revised: February 2016

Group Name:

Group Number:

Please complete the following to provide and/or change access in Online Resources.

Subgroup Access: Named contact/contacts will receive access to the specified subgroup/subgroups.

Online Eligibility: Named contact/contacts will receive access to view and/or modify eligibility in Online Resources.

View Only: Read-only access to online eligibility.

Modify: Ability to make changes through online eligibility.

Billing: Named contact/contacts will receive access to billing.

E-Bill: Access to receive the invoice through email.

Bill by Fax: Access to receive the invoice by Fax.

An email address is required for each contact requesting access to Online Resources.

Enter the information for each contact that is to receive online access through Online Resources. If a contact should have access to all subgroups

then enter “ALL” in the box. Select each type of access. You may choose one method of invoice receipt (E-Bill or Fax). An email address is required.

Add the fax number if selecting Bill by Fax.

Contact Name Online Resources

User Name if previously assigned

Subgroup(s) Access

Select One Online Eligibility

Select One Billing

Email Address required. Please add Fax Number if selecting Bill by Fax. View Only Modify E-Bill Bill by Fax

I , an authorized representative for , approve access to our

account for the persons named above. Through the selection of the above options, I agree my company will receive our monthly bill from

Delta Dental via the above selected option and will remit payment as selected above.

Signature: Date:

Application for Online Resources

DEPENDENT CHILD NAME (LAST) (FIRST) (M.I.) SUFFIX SEX

MALE FEMALESOCIAL SECURITY NUMBER BIRTH DATE

DISABLED*

Employer: __________________________________________________

Subscriber Information: (please complete in ink for enrollment/eligibility updates)SUBSCRIBER NAME (LAST) (FIRST) (M.I.) SUFFIX SEX MARITAL STATUS

M F M SSUBSCRIBER SOCIAL SECURITY NUMBER BIRTH DATE FULL-TIME HIRE DATE COVERAGE EFFECTIVE DATE STATUS

Active COBRA

Retiree Surviving Dep.ADDRESS

CITY STATE ZIP CHECK HERE IF THIS ISA NEW ADDRESS

Dependent Enrollment/Eligibility Update Information: (please complete for spouse and/or dependent children for enrollment/eligibility update)SPOUSE NAME (LAST) (FIRST) (M.I.) SUFFIX SEX

MALE FEMALE

SOCIAL SECURITY NUMBER BIRTH DATE


MALE FEMALE

SOCIAL SECURITY NUMBER BIRTH DATEDISABLED*


MALE FEMALE

SOCIAL SECURITY NUMBER BIRTH DATE

DISABLED*


MALE FEMALESOCIAL SECURITY NUMBER BIRTH DATE

DISABLED*

www.DeltaDentalOK.org

Enrollment/Eligibility Update

LOCATION CODE

WARNING:

Subscriber’sSignature: ______________________ Date: ____

CHANGE IN CURRENT ENROLLMENT STATUS FOR: SUBSCRIBER DEPENDENTS

REASON FOR CHANGE:

DIVORCE NAME CHANGE LEGAL GUARDIANSHIP

OTHER_______________________________________________________________

Other: __________________

SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS, EXPLANATION OF CODES AND PRIVACY POLICY STATEMENT.

PLAN TYPE:(AS ESTABLISHEDBETWEEN EMPLOYERAND DELTA DENTAL)

Enrollment/Eligibility Update Information: EFFECTIVE DATE OF UPDATE/CHANGE/TERMINATION: - -TYPE OF ENROLLMENT/ELIGIBILITY UPDATE:

NEW ENROLLMENT REINSTATEMENT OPEN ENROLLMENT

COBRA ELECTION TERMINATION OF BENEFITS

TERMINATION OF EMPLOYMENT AS OF ______ - ________ - ____________

E-MAIL: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

MARRIAGE

DELTA DENTAL PPO - POINT OF SERVICE

DELTA DENTAL PPO - PLUS PREMIER

DELTA DENTAL PPO - CHOICE ADVANTAGE

DELTA DENTAL PREMIER - CHOICE

DELTA DENTAL PPO - CHOICE

DELTA DENTAL PREMIERDELTA DENTAL PPO

DELTA DENTAL PPO - PLUS PREMIER “ELITE”

DECLINE

ADOPTION

Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, provides false information herein and makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony.

By signing this form, I agree to continue enrollment as provided by the contract between my Employer and Delta Dental of Oklahoma and acknowledge I have read the privacy policy detailed on the back of this form.

GROUP#/SUBGROUP#

GROUP TRANSFER-GROUP#/SUBGROUP# TO: GROUP#/SUBGROUP#

I-DD-ENROLL - 02/16

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S ubs c riber Information - T his section must be completed in order to process your enrollment or update your records . All informationin this section should apply to you, the primary subscriber. P lease print clearly in ink.

F ull-T ime Hire Date: T he date you were hired with your employer.

C overage E ffective Date: T he date Delta Dental coverage takes effect for you (and/or your dependents , if enrolled).

S tatus Definitions (P lease select only one status)

A c tive You are an eligible subscriber.

R etiree You are retired and your employer continues to provide you with dental benefits .

C OB R A You are no longer an active subscriber but you have continued coverage under C OB R A.P leas e c hec k with your human res ourc es or pers onnel department for information regarding C OB R A .

S urviving Dep. T he surviving spouse or child of a deceased subscriber to whom the employer continues to provide benefitsother than under provis ions of C OB R A.

E nrollment/E ligibility Update Information - T his section should only be completed if your are: (1) enrolling yourself or a familymember for the firs t time or (2) if your benefits were terminated and are not being reinstated or (3) if you are making changes to yourcurrent enrollment information.

New E nrollment: C heck for firs t time enrollment for yourself or your eligible dependents .

R eins tatement: C heck for reinstatement coverage for yourself or your eligible dependents .

Termination of C heck only if you are terminating Delta Dental coverage for yourself or a family member.B enefits :

G roup Trans fers : Must be completed when you are transferring from one subgroup to another. (All dependents will transfer)

Dependent E nrollment/E ligibility Update Information - T his section should be completed when: (1) enrolling dependents or(2) if you are submitting updates/changes to Delta Dental enrollment. (P lease include both firs t and last names of any individuals for whomyou are enrolling or submitting an update or change).

Delta Dental of OklahomaP rivacy P olicy

All companies part of the Delta Dental of Oklahoma family of companies (referred to in this Privacy Policy as “Delta Dental”) believe that personal information collected about our customers, subscribers, potential customers, and proposed subscribers (referred to collectively in this Privacy Policy as “Customers”) must be treated with the highest degree of confidentiality. For this reason and in compliance with the Gramm-Leach-Bliley Act of 1999, Delta Dental has developed a Privacy Policy that applies to all employees, officers, directors, agents, brokers, and to any other transaction Delta Dental has which may contain your confidential information. Financial companies are able to choose how they share your personal information, however Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do.

Federal law gives consumers the right to limit information sharing in relation to affiliates' everyday business purposes, information about your creditworthiness, affiliates using your information to market to you, and non-affiliates using your information to market to you. In addition, state laws and other individual companies may give you additional rights to limit sharing.

While we do make available certain nonpublic personal information to non-affiliated third parties in order to service Customer accounts, all information is strictly governed by confidentiality and security agreements to protect our Customers. Therefore, our Customer’s confidential information is protected.

If the group plan is terminated or you terminate your coverage, Delta Dental will adhere to the information practices as described in this notice.

Under no circumstances will we sell information about our Customers or their account to any unaffiliated company, group, or individual without our Customer’s permission.

* Dis abled: Your permanently disabled dependent child. (R equires submiss ion of medical s tatement)

P lease read the following information carefully before completing the other side of this form. You should fill out this form if you are enrolling for coverage or updating/changing any information from an earlier enrollment. If you have any questions about filling out this form, your human resources or personnel department can help you.

Information We Collect - We collect and maintain personal, nonpublic information we receive from Customers directly, through applications, enrollment forms, check, credit or debit card payments, insurance claims, and our website. We also collect your personal information from other companies. The types of personal information we collect and share depend on the product or service you have with us. This information can include your name, address, social security number, date of birth, transaction and claim history, medical information, and checking account information.

Utilization Of Information - Delta Dental has, and will continue to utilize non-affiliated third parties to conduct certain functions of our business in order to provide our Customers with services and products. These functions include processing your requests, claims and transactions, maintaining your account(s), providing information about new products, responding to court orders and legal investigations, reporting to credit bureaus, and to comply with Federal and State Laws. The information Delta Dental uses to provide a service cannot be restricted by our Customers. However, Delta Dental is able to limit this information on your behalf under HIPAA.

If you have any questions about our Privacy Policy, please do not hesitate to contact your Delta Dental representative at 800-522-0188 (Toll Free) or 405-607-2100 (OKC Metro).

Delta Dental does not have any affiliates, nor do we share information with non-affiliates for marketing purposes. When you are no longer our Customer, we will continue to share your information as described in this notice.

Our Security - To protect your personal information from unauthorized access and use, we maintain physical, electronic, and procedural safeguards that comply with Federal Law, including computer safeguards and securedfiles and buildings. We consider nonpublic personal information to be confidential, and treat it as such. The personnel who have access to this information are trained in proper handling of such information. Employees who violate this strict level of confidentiality are subject to our disciplinary process.

Delta Dental PPO‐Plus Premier Federally Compliant Dental plans – For the 2016 plan year, Delta Dental has two

Federally Compliant Plans designed to meet ACA Pediatric Dental Essential Health Benefit standards. Our plans include

the Delta Dental PPO and Premier networks for maximum network access.

Federally Compliant Pediatric Plans for Groups. Individuals are eligible for coverage to age 19 only.

Plan Information: High Option Low Option

Annual Maximum Out‐of‐Pocket: for one covered person to age 19

$350 $350

Annual Maximum Out‐of‐Pocket: for two or more covered persons to age 19

$700 $700

Annual Deductible $25 per person $100 per person

Co‐Insurance – The percentage you will pay for covered services

Plan Information: Co‐Insurance – High Option Co‐Insurance – Low Option

Preventive & Diagnostic Services 0%

No Deductible 0%

$100 Annual Deductible applies

Basic Services 20%

$25 Annual Deductible applies 40%


Major Services 50%

$25 Annual Deductible applies 50%


Medically Necessary Orthodontic Services* 50%

No Deductible 50%

No Deductible

Benefits are based on the State Children’s Health Insurance Program (SCHIP) guidelines. Special processing policies, limitations

and exclusions will apply for medically necessary procedures.

Deductibles and Co‐Insurance will apply to Maximum Out‐of‐Pocket.

Maximum Out‐of‐Pocket does not apply to out‐of‐network services.

* Medically Necessary – Orthodontic treatment and/or services are only covered with orthognathic surgery cases or certain

designated syndromes or genetic disorders such as cleft palate. Benefits are only allowed for medically necessary orthodontic

services to help correct severe handicapped malocclusions caused by cranio‐facial orthopedic deformities involving teeth.

Coverage Type Monthly Rates – High Option Monthly Rates – Low Option

One Covered Person to age 19 $30.51 $18.80

Two Covered Persons to age 19 $61.02 $37.60

Three or more Covered Persons to age 19 $91.53 $56.40

Federally Compliant Dental Plans

Delta Dental Program of Benefits for PPO – Plus Premier Federally Compliant Plans

Delta Dental of Oklahoma’s benefits consist of Preventive & Diagnostic Services, Basic Services, Major Services and Medically

Necessary Orthodontic Services. The benefits listed below are not a complete list. Limitations to benefits can be found in the

Summary Plan Description:

Preventative & Diagnostic Services (Class I Benefits):

Oral evaluation




Topical application of fluoride for eligible children only

Topical application of sealants for eligible children only, limited to permanent first and second molars free of caries and

restorations on the occlusal surface

Basic Services (Class II Benefits):


Stainless steel crowns for eligible children only when the natural teeth cannot be restored with another filling material


Oral Surgery – non‐surgical extractions; medically necessary, non‐prophylactic (diseased) third molar non‐surgical

extractions; incision and drainage of abscess.

Periodontics – procedures performed for the treatment of diseases of the gums and supporting structures of the teeth,

limited to root planing and scaling

Anesthesia – Nitrous oxide/analgesia benefits are limited to invasive procedures (procedures that penetrate the hard or

soft tissue). Nitrous oxide/analgesia is not payable with evaluations and cleanings.

Major Restorative (Class III Benefits):

Major Restorative – provides porcelain or cast restorations (other than stainless steel) when teeth cannot be restored with

another filling material


Oral Surgery Services – Surgical extractions; medically necessary, non‐prophylactic (diseased) third molar surgical

extractions; and other oral surgical procedures

Occlusal guards are a benefit by report for eligible children only when used to prevent the destructive force of bruxism for

periodontal purposes. This is a benefit if the eligible child has periodontal coverage and has had periodontal therapy or is

undergoing therapy.

Medically Necessary Orthodontics (Class IV Benefits):

Orthodontic Benefits are available only with orthognathic surgery cases or certain designated syndromes or genetic

disorders such as cleft palate. Benefits are only allowed for medically necessary orthodontic services to help correct severe

handicapping malocclusions caused by cranio‐facial orthopedic deformities involving the teeth.

Orthodontic coverage is a benefit provided for dependent children only to the age of 19.

Federally Compliant Dental Plans

Delta Dental of OklahomaPost Office Box 54709Oklahoma City, OK 73154 - 1709


$18.80$37.60$56.40

Oct 2015)

$18.80$18.80

Low Option

Low Option

Low Option

(Please complete the reverse side of this Application)

Personto age 19

$30.51$30.51

$30.51$61.02$91.53

CONFIDENTIAL

For Covered Person(s) age 19 and older only (Family Plan only) Maximum Plan Year Benefit Payment: $1,500 Specific Benefit Limitation Period(s): Class II = 6 months Class III = 12 months

For Covered Person(s) under age 19 Maximum Out of Pocket Cost per Benefit Year: $350 - 1 Covered Person $700 - 2 or more Covered Person(s)

ELIGIBILITY/ENROLLMENT: Total Employees Minus Ineligible = Total Eligible Employees :.cte ,emit-trap ,.g.e ,seeyolpmE elbigilenI nialpxE

Employer Contribution to Cost of Plan: Employee Cost % or $ Dependent Cost % or $

Waiting Period for New Enrollees: ____________________________________________________________________________ (Effective date cannot exceed 90 days from date of hire)

Please indicate to whom the new group packet (plan agreement, ID cards, etc.) should be shipped. Producer Group

Form 5500 Information Required? Yes No If “Yes”, reporting timeframe required:

Self-Insured Accounts OnlyAdministrative Fee: $ Per Enrolled Employee Per Month % of Paid Claims Per Month Operating Fund Deposit (please include prefunding check with application):

Claims Reimbursement Options: Weekly Wire Transfer Bi-weekly Wire Transfer Monthly Wire Transfer Weekly Draft Bi-weekly Draft Monthly Draft

Monthly Check

Administrative Fee Payment Options: Weekly Wire Transferr Monthly Wire Transfer Monthly Draft Weekly Draft Monthly Draft Monthly Check

PRODUCER/CONSULTANT INFORMATION: Please complete the information requested below.

Producer/Consultant Social Security No. Agency Federal Tax ID No. Street Address Mailing Address

Business Phone No. ( ) Fax No. ( ) E-Mail Address Website Address

Producer/Consultant Fee Payment Options (if applicable): EFT To Producer/Consultant EFT To Agency

HOLD HARMLESSDelta Dental has not reviewed the employer's request for plan coverage nor designed the group plan to meet any federal requirements for Discriminatory Employee Benefit Plans. Said plan may not be in compliance with criteria established for Discriminatory Employee Benefit Plans, and employer holds Delta Dental Plan of Oklahoma harmless if said plan fails to meet any such requirements.

evah I ot tcerroc dna eurt si evoba noitamrofni llA reviewed the benefits and eligibility requirements detats sa .egdelwonk ym fo tseb eht in this Group Application and accept them.

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Please mark if the following is submitted with this signed application: Enrollment forms Electronic enrollment data

Check for first month’s premium

Form No. 4100.1 (Rev. Oct 2015)

Program Type

(Choose One) Your Cost

Three or more Covered Persons

Program Type (Choose One)

Your Cost

Three or more Covered Persons

Employee Name: ____________________________________________________________ Date of Birth: ________________ Sex: M F

Street Address: ___________________________________________ City: ___________________________________ State: ______ Zip: _________

Social Security #: ________________________ E-mail: ______________________________________________________________

Program Selec on (Choose One)

By signing this form, I agree to con nue enrollment as provided by the contract between my Employer and Delta Dental of Oklahoma and acknowledge I have read the privacy policy on the back of this form.

Applicant Signature:_______________________________________________________ Date: _________________________________

Employer : _______________________________________________________

Pediatric Only High Plan

Other

Eligibility Date

Reason for Change: Name Change Marriage New Address

__ Divorce

Adop on/Guardianship* Termin on of Coverage

Group/Subgroup Transfer From Group/Subgroup

Pediatric Only Low Plan

Enrollment/Eligibility Update Informa on:

To Group/Subgroup

Mail to: Delta Dental of Oklahoma A n: Health Care ReformTeam PO Box 54709 Oklahoma City, OK 73154

Fax to: 1-405-607-2199

Email to:

Change in Status for: Subscriber Dependent(s)

E ctive Date of Update/Change/Termination

TURN OVER/NEXT PAGE >>

Delta Dental PPO Plus Premier Federally Compliant PlansEnrollment Form

Please list all Covered Persons under the age of 19 to be enrolled. Each Covered Person's SSN MUST be provided

Covered Person: _______________________________________ Sex: ______ SSN: ___________________ Date of Birth: ___________

Sex: ______ SSN: ___________________ Date of Birth: ___________

________ :NSS ______ :xeS ___________ Date of Birth: ___________




Covered Person: _______________________________________

Covered Person: _______________________________________

Covered Person: _______________________________________

Covered Person: _______________________________________

Covered Person: _______________________________________


SEE REVERSE SIDE OF THIS FORM FOR PRIVACY POLICY STATEMENT Group/Subgroup Location Code

One Covered Person $ 30.51 per month

Two Covered Persons $ 61.02 per month

$ 91.53 per month

One Covered Person $ 18.80 per month

Two Covered Persons $ 37.60 per month

$ 56.40 per month

PedEnroll (10/15)

[email protected]

Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, provides false inform on herein and makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading inform on is guilty of a felony.

*Legal Documents Must Be Submitted for Update/Change

Delta Dental of Oklahoma Privacy Policy

Revised 06/2010

All companies part of the Delta Dental of Oklahoma family of companies (referred to in this Privacy Policy as “Delta Dental”) believe that personal information collected about our customers, subscribers, potential customers, and proposed subscribers (referred to collectively in this Privacy Policy as “Customers”) must be treated with the highest degree of confidentiality. For this reason and in compliance with the Gramm-Leach-Bliley Act of 1999, Delta Dental has developed a Privacy Policy that applies to all employees, officers, directors, agents, brokers, and to any other transaction Delta Dental has which may contain your confidential information. Financial companies are able to choose how they share your personal information; however Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. Information We Collect – We collect and maintain personal, nonpublic information we receive from Customers directly, through applications, enrollment forms, check, credit or debit card payments, insurance claims, and our website. We also collect your personal information from other companies. The types of personal information we collect and share depend on the product or service you have with us. This information can include your name, address, social security number, date of birth, transaction and claim history, medical information, and checking account information. Utilization Of Information – Delta Dental has, and will continue to utilize non-affiliated third parties to conduct certain functions of our business in order to provide our Customers with services and products. These functions include processing your requests, claims and transactions, maintaining your account(s), providing information about new products, responding to court orders and legal investigations, reporting to credit bureaus, and to comply with Federal and State Laws. The information Delta Dental uses to provide a service cannot be restricted by our Customers. However, Delta Dental is able to limit this information on your behalf under HIPAA.

Federal law gives consumers the right to limit information sharing in relation to affiliates’ everyday business purposes, information about your creditworthiness, affiliates using your information to market to you, and non-affiliates using your information to market to you. In addition, state laws and other individual companies may give you additional rights to limit sharing.

Delta Dental does not have any affiliates, nor do we share information with non-affiliates for marketing purposes. When you are no longer our Customer, we will continue to share your information as described in this notice. Our Security - To protect your personal information from unauthorized access and use, we maintain physical, electronic, and procedural safeguards that comply with Federal Law, including computer safeguards and secured files and buildings. We consider nonpublic personal information to be confidential, and treat it as such. The personnel who have access to this information are trained in proper handling of such information. Employees who violate this strict level of confidentiality are subject to our disciplinary process. While we do make available certain nonpublic personal information to non-affiliated third parties in order to service Customer accounts, all information is strictly governed by confidentiality and security agreements to protect our Customers. Therefore, our Customer’s confidential information is protected. If the group plan is terminated or you terminate your coverage, Delta Dental will adhere to the information practices as described in this notice.

If you have any questions about our Privacy Policy, please do not hesitate to contact your Delta Dental representative at 800-522-0188 (Toll Free) or 405-607-2100 (OKC Metro).

Under no circumstances will we sell information about our Customers or their account to any unaffiliated company, group, or individual without our Customer’s permission.

Features & Services Delta Dental of Oklahoma provides numerous tools and

services to help you get the most out of your dental benefits.

From online services to multiple provider networks,

Delta Dental of Oklahoma has your smile covered.

S-04, Revised: 04/27/16

If you visit a Delta Dental PPO participating dentist, you are not responsible for any amounts in excess

of Delta Dental’s PPO maximum allowable amount. Members enrolled in a Delta Dental Plus Premier plan enjoy no balance-billing with any participating network provider.

Our Oklahoma based Customer Service Department is just a phone call away. Customer Service Representatives

can be reached at 405-607-2100 or toll free at 1-800-522-0188 and are available Monday through Friday from 7am to 6pm. Oral health tips, our Find a Dentist tool and many other services are available to you 24/7 at DeltaDentalOK.org.

Delta Dental offers two of the nation’s largest dental provider networks. Delta Dental Premier

consists of more than two-thirds of the nation’s dentists. Delta Dental PPO consists of nearly 50% of the nation’s dentists and typically provides lower out-of-pocket costs.

Spotlight is online, real-time, 24/7 secure access to benefit information you want – when you want it.

Our online services provide:• Claims Status• Find a Dentist• Prevent-O-Meter• Oral Health Education and more!

To register for Spotlight, visit: DeltaDentalOK.org/Spotlight

My Mouth Dental procedure codes and tooth numbers can be confusing. That is why we provide a My Mouth chart in Spotlight. This chart is a graphic illustration of your teeth, with color codes that show dental work, as well as an explanation of the procedures performed on each tooth. It is a tool that can help you better understand the dental care you receive.

Access Your Explanation of Benefits (EOB) Your EOB is the key to understanding how Delta Dental of Oklahoma pays your claims. Spotlight gives you the freedom to access your EOB before you receive it in the mail. You can also view your history for up to seven years so you don’t have to search for paper documents should you need to revisit a claim.

Print Your ID Card While you don’t have to bring your ID card with you when you visit your dentist, sometimes having it brings peace of mind that your claims will be paid appropriately. With Spotlight, you have 24/7 access to view, print, save or email your ID card directly from your computer.

View My Benefits In order to take full advantage of your dental benefits, you have to have a good understanding of what they are. Spotlight makes that easy with the View My Benefits tool. Here you can see a list of what your dental plan covers and what, if any, limitations apply. You can also view your benefits as a PDF to easily print, save and email, when necessary.

SpotlightTM Multiple ProviderNetworks

No Balance Billing

Customer Service

For Members

Mobile Features & ServicesFor quick, on-the-go dental benefits information, there’s

the Delta Dental Mobile App. The mobile app is perfect for

those benefit questions that arise when you are out and

about and need a quick answer right at your fingertips.

Our mobile website is another convenient way to access

contact information and other valuable resources 24/7.

Securely Access Benefits With Delta Dental’s free mobile app you can stay up-to-date on

coverage information, plan type, benefit levels, contact information,

deductibles and maximums. You can check the status of your most

recent dental claims, view details and even email claim information

for both you and your dependents under age 18. In order to securely

access this information, be sure to register on the DeltaDental.com

website and login using your mobile device.

Contact Information If you ever have a question about your dental benefits plan, how we

paid a claim or simply need clarification, we are just a phone call or

email away. Our contact information for Customer Service, Sales and

Client Relations, to name a few, is easily located on the

DeltaDentalOK.org mobile website.

S-04, Revised: 4/27/16

Additional Tools The mobile app provides a comprehensive Find a Dentist tool where

you can search all networks. This field will automatically default to your

plan if you are logged in but is available to all users without logging in

as well. You can also view your mobile ID card or even email your card

to your dental office or dependents. The mobile app comes complete

with a musical toothbrush timer so you and your dependents can stay

up-to-date with your oral wellness routine.

Valuable Resources With multiple avenues to find a dentist and brush up on your oral

wellness tips, our mobile website makes keeping up with your oral

wellness routine easy.

Mobile App Mobile Website

For Members

Delta Dental vision provided by EyeMedYour eyes say a lot about you – from your emotions to vision and your overall health. And, when you’re proactive about protecting your eyes, the impact is clear.

Regular eye exams not only correct vision problems, they also can reveal early warning signs of more serious health conditions such as hypertension, cardiovascular disease and diabetes. So, schedule exams annually and you’ll be set on a path to better health.

Keep on savingYou can use your EyeMed discount as often as you like, all year long, on nearly all your vision care purchases at EyeMed’s participating providers.

Visit deltadental.com to learn more

Need to locate a provider? Want to learn about vision wellness? Visit deltadental.com.

Please note your discount cannot be combined with any other discounts, coupons or promotional offers.

Locate a providerYou love choices - and so do we. That’s why our network has thousands of independent doctors and retail providers.

Schedule an appointmentCall ahead or stop by one of the many providers that offer walk-ins. Most also have evening and weekend hours to fit any schedule.

Show your ID cardWhen you arrive, let the provider know you have an EyeMed discount through Delta Dental.

Please detach carefully at perforation and keep card in your wallet.ASSET NUMBER

Member/Patient Services: 1.866.723.0391ACCESS DISCOUNT PLAN

DELTA DENTALDiscount Plan Number

9231093

Signature:

This is not insurance.Dependents are eligible. deltadental.com

See better – live better

Delta DentalDiscount plan Access networkDiscounted exam and a defined materials discount

Vision care servicesExam and dilation as necessary $5 off routine exam $10 off contact lens exam

Complete pair of glasses purchase*:Frame, lenses and lens options must be purchased in the same transaction to receive full discount.

Standard plastic lenses:Single Vision $50Bifocal $70Trifocal $105

Frames 35% off retail price

Lens options:UV treatment $15Tint (solid and gradient) $15Standard plastic scratch coating $15Standard polycarbonate $40Standard progressive lens (Add-on to bifocal) $65Standard anti-reflective coating $45Other add-ons and services 20% off retail price

Contact lens materials: (Discount applied to materials only)Disposable 0% off retail priceConventional 15% off retail price

Laser vision correction**: LASIK or PRK 15% off retail price or 5% off promotional price

Frequency:Examination UnlimitedFrame UnlimitedLenses UnlimitedContact lenses Unlimited

Member cost

THIS IS NOT INSURANCE

*Items purchased separately will be discounted 20% off of the retail price.**Since LASIK and PRK vision corrections are elective procedures, performed by specially trained providers, this discount may not always be available from a provider in your location. For a location near you and the discount authorization, please call 1.877.5LASER6.Member will receive a 20% discount on those items purchased at participating providers that are not specifically covered by this discount. The 20% off discount does not apply to EyeMed providers' professional services or contact lenses. Retail prices may vary by location. All discounts cannot be combined with any other discounts or promotional offers. This discount design is offered with the EyeMed Access panel of providers.

Visit eyemedvisioncare.com/deltad for more information or to locate a provider near you.

Limitations/Exclusions:• Orthoptic or vision training, subnormal vision aids and any associated supplemental testing• Medical and/or surgical treatment of the eye, eyes or supporting structures• Corrective eyewear required by an employer as a condition of employment and safety eyewear unless specifically covered under plan• Services provided as a result of any Worker’s Compensation law• Discount is not available on those frames where the manufacturer prohibits a discount

EyeMed Member/Patient Services: Visit eyemed.com or call the number on the front of this card.

EyeMed Doctors/Providers Only: Visit eyemed.com to receive plan information or authorization online or call 1.800.521.3605.

SPOTLIGHTANSWERS ARE ALWAYS AT YOUR FINGERTIPSNew subscribers to Delta Dental plans tend to have a lot of

questions. SPOTLIGHT is Delta Dental of Oklahoma’s online

portal for dental plan subscribers that answers most of those

questions before they are even asked.

Since SPOTLIGHT allows 24/7 access, subscribers can

manage their dental benefits at the time and place of

their choosing.

Here are a few ways you can use Spotlight any time any day:

• Print your dental benefits ID card

• Review your claims status and claims history

• Review your benefit plan information

• Review your eligibility for treatment

• Find a Delta Dental network dentist

• Access a Delta Dental claim form (for out-of-network treatment)

REGISTER TODAY!Visit DeltaDentalOK.org/spotlight to register for your exclusive

login information to access Spotlight any time any day.

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