Delta Dental Indiana

Delta Dental Small Group Dental Solutions
(2–9 enrolled employees)
INDIANA
Plan A Plan B Plan C Plan D Plan E
Delta Dental PPO Delta Dental PPO Delta Dental PPO Delta Dental PPO Delta Dental PPO
(Point-of-Service) (Point-of-Service) (Point-of-Service) (Point-of-Service) (Standard)
Plan pays Plan pays Plan pays Plan pays Plan pays
Delta Dental Delta Dental Delta Dental Delta Dental Delta Dental Delta Dental Delta Dental Delta Dental
PPO Premier* PPO Premier* PPO Premier* PPO Premier*
Preventive & diagnostics 100% 1 80% 1 80% 1 80% 1 100% 1 80% 1 50% 50% 80%
X-rays 80% 60% 80% 1 80% 1 80% 60% 50% 50% 80%
Minor restorative services 80% 60% 60% 60% 80% 60% 50% 50% 60%
Periodontal maintenance 80% 60% 60% 60% 80% 60% 50% 50% 60%
Relines and repairs 80% 60% 60% 60% 80% 60% 50% 50% 60%
Simple extractions 80% 60% 40% 40% 80% 60% 50% 50% 40%
Endodontics 50% 2 50% 2 40% 40% 0% 0% 50% 2 50% 2 40%
Periodontics 50% 2 50% 2 40% 40% 0% 0% 50% 2 50% 2 40%
Other oral surgery 50% 2 50% 2 40% 40% 0% 0% 50% 2 50% 2 40%
Other basic services 50% 2 50% 2 40% 40% 0% 0% 50% 2 50% 2 40%
Major restorative services 50% 2 50% 2 40% 40% 0% 0% 50% 2 50% 2 40%
Prosthodontics (dentures, bridges, implants) 50% 2 50% 2 40% 40% 0% 0% 50% 2 50% 2 40%
* Providers who do not belong to either of Delta Dental’s two networks will be paid at the same copayment levels as Delta Dental Premier dentists. Payments to these providers will be based on Delta Dental’s
nonparticipating dentist fee schedule and patients may be balance billed.
1
The deductible is waived for these services.
2
Indicates a 12-month waiting period. The waiting periods can be waived for employees previously enrolled in an equivalent plan for the 12 months prior to the client’s initial effective date. Proof of prior dental
coverage is required with the new Client Information Form for clients who wish to have the waiting periods waived.
Deductible (per person per calendar year) $75 $75 $75 $75 $75 $75 $75 $75 $75
Maximum payment (per person per calendar year) $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000
Exams/prophylaxes 2 per calendar year 2 per calendar year 2 per calendar year 2 per calendar year 2 per calendar year
Fluoride (to age 19)/bitewing X-rays 1 per calendar year 1 per calendar year 1 per calendar year 1 per calendar year 1 per calendar year
Brush biopsy/posterior composites Included Included Included Included Included
Orthodontia Not available Not available Not available Not available Not available
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Plan rates below are for clients with effective dates between 10/1/12–9/30/13
Plan A Plan B Plan C Plan D Plan E
Delta Dental PPO Delta Dental PPO Delta Dental PPO Delta Dental PPO Delta Dental PPO
(Point-of-Service) (Point-of-Service) (Point-of-Service) (Point-of-Service) (Standard)
Standard High Risk Standard High Risk Standard High Risk Standard High Risk Standard High Risk
Indiana Single $27.10 $30.09 $26.13 $29.02 $17.24 $19.16 $19.14 $21.25 $22.33 $24.81
2 Party $48.79 $54.20 $47.31 $52.56 $31.09 $34.54 $34.41 $38.22 $40.40 $44.88
Family $86.33 $95.88 $83.62 $92.89 $62.36 $69.27 $57.63 $64.01 $71.69 $79.63
Rates shown are per month per employee and are valid for a 12-month contract.
To enroll
Complete the Client Information Form and
return to Delta Dental along with enrollment
information, proof of prior dental coverage (if
applicable) and a check for the group’s first
month’s premium.
Submit to:
Delta Dental
Attn: Group Administration
PO Box 30416
Lansing, MI 48909
To download the Client Information Form,
visit the Producers section of our website
at www.deltadentalin.com.
Questions?
Call us today at (800) 382-5404 to learn
more about Delta Dental’s plans.
NOTE: Rates shown above are for clients with
effective dates between 10/1/12–9/30/13.
Participation
requirements
Number
eligible
Minimum
number insured
2 2
3 3
4 3
5 4
6 4
7 4
8 5
9 5
10–18 50%
NOTE: Immediate family members
must be enrolled together on
one application and count as one
eligible member.
At least 75 percent of the employees
must be physically located in the
state where the contract is held.
High-risk occupations
The following industry groups require the “high-risk occupation” rate adjustment:
Amusement/entertainment groups
(amusement parks, casinos, movie
theatres, pool halls)
Auto sales and service (new and used
auto sales, car washes, repair shops)
Bars/taverns
Construction firms/contractors
Garbage operations
Gas stations
Health/sport/country clubs
Hotels/motels
Insurance agencies
Janitorial services
Junk/scrap/salvage yards
Laundry/dry cleaning
Liquor stores
Movers/trucking operations
Nursing homes
Parking lot facilities
Pawn shops/used merchandise stores
Professional offices (doctors,
lawyers, architects)
Real estate agencies
Religious organizations
Restaurants
Security guard services
Studios (dance, theatrical
groups, photography)
Taxi/transportation services
The following industry groups are not eligible for coverage, however they may be
eligible for coverage through our individual product offerings. Contact your Delta Dental
sales representative for more information.
1099 contractors
Beauty/barber shops
Leased employees
Private households
Seasonal work (farming and
agricultural labor)
6122-IN v5 Rate Sheet
cc 8/12