Delta Dental benefits for AAA members

Transcription

1 benefits for AAA members Affordable dental benefits exclusively for AAA Ohio Auto Club members.

2 Good health starts with a healthy smile A healthy smile is important not only to your oral health, but for your overall health, too. Untreated oral disease can make many health problems worse. In fact, your dentist can detect more than 120 non-dental diseases including cancer, diabetes, heart disease, kidney disease, and osteoporosis during a routine oral exam.* Having dental coverage helps you get the care you need to stay healthy. It can also help keep your overall health care costs down. That s why AAA Ohio Auto Club is pleased to offer you exclusive dental benefits through. After all, good health starts with a healthy smile! *Sources: J Am Dent Assoc, Vol 134, No suppl_1, 41S-48S American Dental Association and Dental Management of the Medically Compromised Patient, 7th Edition, 2008, Mosby Elsevier, St. Louis, MO.

3 Frequently asked questions about Enroll for dental benefits today! To enroll in this program, fill out the enrollment form and submit with payment to. There are three easy ways to enroll; choose the option that is most convenient for you: Access AAA Ohio Auto Club s member website and electronically submit the enrollment form. Call s Customer Service department at (800) and complete your enrollment over the phone. Fill out the enrollment form attached to this brochure and mail to: Collection Center Drive Chicago, IL Effective date for coverage You must enroll 15 days prior to the effective date. The effective date for your coverage is always the first day of a month: For example: If you enroll by March 15th, your effective date for coverage will be April 1st. If you enroll after March 15th, your effective date for coverage will be May 1st. You must remain enrolled for at least 12 months. If you are not satisfied with your policy when you receive it, you will have 10 days to return it. Once you drop coverage, you cannot re-enroll. How does this program work? The AAA Ohio Auto Club members program is a PPO SM (Point-of-Service) program. As a AAA Ohio Auto Club member, you will receive high levels of coverage for routine services you need to stay healthy. Can I enroll my family members? Yes. This program offers one-person, two-person, or family rates. What are the rates for this program? The rates for coverage depend on the number of people enrolled and the payment option you select (monthly or annual payment). You can choose the option that best fits your needs. Rates are listed on the attached enrollment form. Do my family members and I have to visit a particular dentist? No. You and your family members are free to visit any dentist, regardless of whether that dentist participates in our networks. However, you will save money and receive higher levels of coverage when you visit a participating dentist. How can I find a participating dentist near me? s networks of participating dentists are the largest available anywhere, so it s easy to find participating dentists near you. Three out of four dentists nationwide participate in one or more programs, so it s likely that your current dentist is among them. To get the names of participating dentists near you, use the dentist search at What if I go to a nonparticipating dentist? If you go to a dentist who does not participate with, you ll still be covered, but you may have to pay more. We ll pay you directly for covered services based on the dentist s submitted fee or s nonparticipating dentist fee, whichever is less. You ll be responsible for paying the dentist whatever he or she charges. You may also have to submit your own claims. Do I have to fill out and submit a claim form? You do not have to fill out and submit claim forms when you visit participating dentists. You may have to fill out and submit your own claims if you visit a nonparticipating dentist. Do I need an ID card to receive care? No. Your dentist can verify your eligibility for coverage without one. How do I know what s covered under my plan? This plan s coverage levels and savings depend on whether you visit a participating PPO dentist or a Delta Dental Premier or nonparticipating dentist. You will save the most money and maximize your benefits when you visit a participating PPO dentist. Your coverage levels are indicated below: Premier or PPO Dentist Non-par Dentist CLASS I Diagnostic and Preventive Services 100% 80% Bitewing Radiographs (X-rays) 100% 80% Emergency Palliative Treatment 70% 60% Space Maintainers 70% 60% CLASS II All Other Radiographs 70% 60% Minor Restorative Services (Fillings) 70% 60% Simple Extractions 70% 60% *Prosthodontic Repair 50% 50% *Major Oral Surgery 50% 50% *Periodontics 50% 50% *Endodontics (Root Canals) 50% 50% CLASS III *Prosthodontics (Bridges & Dentures) 50% 50% *Major Restorative Services (Crowns) 50% 50% Maximum payment: $1,000 per person per calendar year for Class I, II, and III benefits. Deductible: $25 deductible per person total per calendar year on emergency palliative treatment, space maintainers, Class II and III benefits. The deductible does not apply to the balance of Class I Benefits. *You must be enrolled for 12 months before will pay for these services. Payment is based on the participating status of the dentist: PPO based on dentist s submitted fee or the PPO dentist fee schedule, whichever is less; Premier based on dentist s submitted fee or the maximum approved fee on the Premier dentist fee schedule, whichever is less; and non-par based on dentist s submitted fee or s nonparticipating dentist fee, whichever is less. NOTE: This summary is a sample of benefits. Policies have exclusions and limitations that may limit coverage. For complete coverage details, please refer to your policy.

4 Individual Dental Enrollment/Update Please fill out this form if you are enrolling for individual dental coverage for the first time or if you are changing any information from an earlier enrollment. If you have any questions about completing this form, please contact s Customer Service department at (800) For use only: Policy # - Coverage Effective Date: New Enrollment Check for first-time enrollment for yourself and/or your dependents. Change/Correction to Information Check if any changes are being submitted on this form. Termination of Benefits Check only if you are terminating coverage for yourself or your dependents. Please refer to your Summary of Dental Plan Benefits and Policy for rules regarding termination. Enrollee Information (This section must be completed for us to process your enrollment or update your records. Please print clearly or type.) Items in red are required. Name (First) (M.I.) (Last) Sex M F Birth Date (MM/DD/YYYY) Social Security Number AAA Member Number Street Address Check here if this is a new address City State ZIP Code Address Telephone Number Spouse and Dependent Information (Please complete this section if you are enrolling your spouse or dependent(s) for the first time or if you have checked Change/Correction above and are changing information about your spouse and/or dependent(s) that were previously submitted to. You must include all first and last names. Please attach a separate sheet for additional dependents.) Spouse Name (First) (M.I.) (Last) Birth Date (MM/DD/YYYY) Sex M F Social Security Number Dependent #1 Name (First) (M.I.) (Last) Birth Date (MM/DD/YYYY) Sex M F Social Security Number Dependent #2 Name (First) (M.I.) (Last) Birth Date (MM/DD/YYYY) Sex M F Social Security Number Payment Information (The amount payable for coverage varies based on the coverage option selected, the number of people enrolled, and the payment option you select. You may choose only one option, regardless of the number of people enrolling.) Please note: If you are paying by check, you must choose annual payment. If you are paying by credit card or automatic withdrawal, you may choose monthly or annual payment. These rates are valid for one year from the effective date of your coverage. Monthly payment Annual payment (credit card or auto withdrawal ONLY) Single ($34.96) Single ($398.52) 2 people ($66.16) 2 people ($754.20) Family ($117.55) Family ($1,340.04)

5 Choose the payment method: Check payable to You may pay by check only if you pay the full annual payment. To pay by check, you must use this application and mail to us at the address listed to the right. Your check for the full amount must accompany this application. Please mail enrollment form and check to: Collection Center Drive Chicago, IL MasterCard Visa Card Number Exp. Date / Cardholder Name (as it appears on card) Credit Card Billing Address (if different from mailing address) Street Address City State ZIP Code I hereby authorize, or any of its affiliates, to charge my credit card for premiums due. This authorization will remain in effect until has received written notice from me of its termination and/or my payment obligation has been satisfied. If the billing amount changes, will provide a minimum of 10 days notice to the cardholder. Cardholder s Signature Date Automatic withdrawal from bank account Bank Name Checking Account OR Savings Account Routing Number Account Number I hereby authorize, or any of its affiliates, to initiate automatic withdrawals (ACH) from the account indicated above. This authorization will remain in effect until has received written notification from me of its termination and/or my payment obligation has been satisfied. I understand that I am responsible for any fees incurred due to my payment being rejected for processing by my bank. If the billing amount changes, will provide a minimum of 10 days notice to the cardholder. Account Holder s Signature Date Validation Question (choose ONE and answer below): Mother s maiden name (last name only) OR City in which you were born OR Name of first pet Answer: By signing this Individual Dental Enrollment/Update form, you certify that the information provided herein is true to the best of your knowledge. You further agree to be legally bound by the terms contained herein and the terms contained in the dental benefits policy issued pursuant to your application for dental benefits coverage. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Signature Date

6 Questions? If you would like more information about these benefits, please visit AAA Ohio Auto Club s website, If you have questions about this information or about your coverage once you ve enrolled, please call our Customer Service department at (800) Plan of Ohio, Inc. 550 Polaris Parkway, Suite 550 Westerville, OH v3 AAA Ohio Auto Club 90 E. Wilson Bridge Road Worthington, OH POS # /11 cc

7 Frequently asked questions about benefits for AAA members How does this program work? The AAA Ohio Auto Club members program is a regular PPO (Point-of-Service) program. As a AAA Ohio Auto Club member, you will receive the highest level of coverage for routine services you need to stay healthy. How do I enroll? To enroll in this program, fill out an enrollment form and submit it with payment to. There are three easy ways to enroll; choose the option that is most convenient for you: Access AAA Ohio Auto Club s member Web site and electronically submit the enrollment form. Call s Customer Service department at (800) and complete your enrollment over the phone. Pick up an enrollment form from any AAA Ohio Auto Club office, fill out the form, and mail to: Collection Center Drive Chicago, IL Can I enroll my family members? Yes. This program offers one-person, two-person, or family rates. Do my family members and I have to visit a particular dentist? No. You and your family members are free to visit any dentist, regardless of whether that dentist participates in our networks. However, you will save money and receive higher levels of coverage when you visit a participating dentist. How can I find a participating dentist near me? s networks of participating dentists are the largest available anywhere, so it s easy to find participating dentists near you. Three out of four dentists nationwide participate in one or more programs, so it s likely that your current dentist is among them. To get the names of participating dentists near you, visit of Ohio s Web site at What if I go to a nonparticipating dentist? If you go to a dentist who does not participate with, you ll still be covered, but you may have to pay more. We ll pay you directly for covered services based on the dentist s submitted fee or s nonparticipating dentist fee, whichever is less. You ll be responsible for paying the dentist whatever he or she charges. You may also have to submit your own claims. What are the rates for this program? The rates for coverage depend on the number of people enrolled and the payment option you select (monthly or annual payment). You can choose the option that best fits your needs. Rates are listed below: Monthly payment (credit card or auto withdrawal only) Annual payment Single person ($29.66) Single person ($338.04) Two person ($56.12) Two person ($639.72) Family ($99.71) Family ($1,136.64) What is the effective date for coverage? You must enroll 15 days prior to the effective date. The effective date for your coverage is monthly: For example: If you enroll by March 15th, your effective date for coverage will be April 1st. You must remain enrolled for at least 12 months. If you are not satisfied with your policy when you receive it, you will have 10 days to return it. Once you drop coverage, you cannot re-enroll.

8 How do I know what s covered under my plan? This plan s coverage levels and savings depend on whether you visit a participating PPO dentist or a Premier or nonparticipating dentist. You will save the most money and maximize your benefits when you visit a participating PPO dentist. Your coverage levels are indicated below: Premier or Nonparticipating PPO Dentist: Dentist: Class I Diagnostic and Preventive Services 100% 80% Bitewing Radiographs (X-rays) 100% 80% Emergency Palliative Treatment 70% 60% Space Maintainers 70% 60% Class II All Other Radiographs 70% 60% Minor Restorative Services (fillings) 70% 60% Simple Extractions 70% 60% *Prosthodontic Repair 50% 50% *Major Oral Surgery 50% 50% *Periodontics 50% 50% *Endodontics (root canals) 50% 50% Maximum payment: $1,000 per person total per calendar year for Class I, II, and III benefits. Deductible: $25 deductible per person total per calendar year on emergency palliative treatment, space maintainers, Class II and III benefits. The deductible does not apply to the balance of Class I Benefits. *You must be enrolled for 12 months before will pay for these services. Do I have to fill out and submit a claim form? No. You do not have to fill out and submit claim forms when you visit participating dentists. You may have to fill out and submit your own claims if you visit a nonparticipating dentist. Do I need an ID card to receive care? No. Your dentist can verify your eligibility for coverage without one. More questions? If you would like more information about, please visit Delta Dental of Ohio s Web site at If you have questions about this information or about your coverage once you ve enrolled, please call s Customer Service department at (800) Class III *Prosthodontics (bridges & dentures) 50% 50% *Major Restorative Services (crowns) 50% 50% E6060 cc 2/10