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Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Dental Insurance Delta Dental PPO Plan The Sheriff's Office offers dental insurance through Delta Dental to benefit- Out-of-Network Benefits eligible employees.The monthly cost for coverage is listed in the premium table below and a brief summary of benefits is provided on the following Out-of-network benefits are used when members receive services by a non- page.For more detailed information about the dental plan,please refer to the participating Delta Dental PPO provider. Delta Dental reimburses out of carrier's summary plan document or contact Delta Dental's customer service. network services based on what it determines is the Maximum Plan Allowance (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 Dental Insurance—Delta Dental PPO* an out-of-network dentist,the member may be responsible for balance billing. Payroll Deductions-Monthly Premiums Balance billing is the difference between Delta Dental's MPA and the amount Tier of Coverage Employee Cost charged by the out-of-network dental provider.Balance billing is in addition to any applicable plan deductible or coinsurance responsibility. Employee Only T� $11.07 Employee+Family $27.15 Calendar Year Deductible *Group#01176 The dental PPO 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. In-Network Benefits The deductible is waived for diagnostic,preventive and orthodontic services. Once$150 total (aggregate)is met for the in-network and out-of--network The dental PPO plan provides benefits for services received from in-network deductible for a family,regardless of who incurs the expenses,the deductible and out-of-network providers.It is also an open access plan which allows for will then be considered met for all covered members in that family. services to be received from any dental provider without having to select a Primary Dental Provider(PDP)or obtain a referral to a specialist.The network Calendar Year Benefit Maximum of participating dental providers the plan utilizes is the Delta Dental PPO The maximum benefit(coinsurance)the dental PPO plan will pay for each network. These participating dental providers have contractually agreed to accept Delta Dental's contracted fee or"allowed amount"This fee is the covered member is $1500 for in network and out-of-network services maximum amount Delta Dental provider can charge a member for a service. combined.Diagnostic and preventive services do not accumulate towards the The member is responsible for a Calendar Year Deductible (CYD) and then benefit maximum.Once the plan's benefit maximum is met,the member will coinsurance based on the plan's charge limitations. be responsible for future charges until next calendar year. Please Note:If a member is not able to use a Delta Dental PPO provider,then services can Orthodontia Lifetime Benefit Maximum be received from a Delta Dental Premier®Provider.Delta Dental Premier®Providers are The maximum benefit the dental PPO plan will pay for each covered member considered out-of-network dentists.These dentists have agreed to accept Delta Dental's per lifetime for the treatment of orthodontia is $1,500 for in-network and Maximum Plan Allowance(MPA)for each single procedure;however,the provider may out-of-network services.Once the dental PPO plan pays$1,500 for services, still bill for the difference of the MPA and the Premier Dental Agreement amount. The member's plan benefits will cease for the lifetime of that covered member for member is responsible for verifying whether the treating dentist is a PPO Dentist or Premier Dentist orthodontic services. Delta Dental I Customer Service:(800)521-2651 I www.deltadentalins.com 120 11 ©2016,Gehring Group,Inc.,All Rights Reserved