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Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Dental Insurance Delta Dental Table of Allowance (TOA) Plan The Sheriff's Office offers dental insurance through Delta Dental to Out-of-Network Benefits benefit-eligible employees. The monthly cost for coverage is listed in the premium table below and a brief summary of benefits is provided on the Out-of-network benefits are used when member receives services by a non- following page.For more detailed information about the dental plan,please participating Delta Dental PPO provider. Delta Dental reimburses out of refer to the carrier's summary plan document or contact Delta Dental's network services based on what it determines is the Maximum Plan Allowance customer service. (MPA).The MPA is defined as the most common charge for a particular dental procedure performed in a specific geographic area.If services are received from an out-of-network dentist,the member may be responsible for balance billing. Dental Insurance Balance billing is the difference between Delta Dental's MPA and the amount Delta Dental Table of Allowance(TOA)Plan* charged by the out-of-network dental provider.Balance billing is in addition to Premium Deductions-Monthly Premiums any applicable plan deductible,plan allowances or coinsurance responsibility. Tier of Coverage Employee Cost Using a non-Delta Dental provider usually results in the highest out of pocket costs,there is no limit to the amount the dentist may charge,causing member Employee only $7:99 to be responsible for any fees not covered by the plan's Maximum Plan Employee+Family $19.59 Allowance. *6roupk 01276 Calendar Year Deductible In-Network Benefits The TOA plan requires a$50 individual or a$150 family deductible to be met for in-network or out-of-network services before most benefits will begin. The TOA plan provides benefits for services received from in-network and The deductible is waived for diagnostic,preventive and orthodontic services. out-of-network providers. It is also an open-access plan which allows for Once $150 total (aggregate) is met for the in-network and out-of-network services to be received from any dental provider without having to select a deductible for a family,regardless of who incurs the expenses,the deductible Primary Dental Provider(PDP) or obtain a referral to a specialist. Although will then be considered met for all covered members in that family. the Delta Dental TOA plan allows member the freedom to visit any licensed dentist, member will receive greater cost savings by utilizing participating Calendar Year Benefit Maximum dental providers in the Delta Dental PPO network.These participating dental The maximum benefit(coinsurance) the dental TOA plan will pay for each providers have contractually agreed to accept Delta Dental's PPO dental fee covered member is$1500 for in-network or out-of-network services combined. or"allowed amount."This dental fee is the maximum amount a Delta Dental provider can charge a member for a service.The member is responsible for a All services, including diagnostic and preventive, accumulate towards the Calendar Year Deductible(CYD)and then the difference of the Maximum Plan benefit maximum.Once the plan's benefit maximum is met,the member will Allowance(MPA)charge and the"allowed amount."The MPA is generally less be responsible for future charges until next calendar year. than the allowed amount. Orthodontia Lifetime Benefit Maximum Please Note:If a member is not able to use a Delta Dental PPO provider,then services The maximum benefit the dental TOA Plan will pay for each covered member can be received from a Delta Dental Premier®provider.Delta Dental Premier®providers per lifetime for the treatment of orthodontia is$1,500 for in-network and out- are considered out-of-network dentists.The dentists have agreed to accept Delta Dental's of-network services.Once the dental plan pays$1,500 for services,member's Maximum Plan Allowance(MPA)for each single procedure however,the provider may plan benefits will cease for the lifetime of that covered member for orthodontic bill for the difference of the MPA and the Premier Dental Agreement amount.Member is responsible for verifying whether the treating Dentist is a PPO Dentist ora Premier services. Dentist. Delta Dental I Customer Service:(800)521-2651 I www.deltadentalins.com 118 9 ©2016,Gehring Group,Inc.,All Rights Reserved