2015 small busiess CALIFORNIA Detal plas ad rates For effective dates Jauary 1 December 1, 2015 Souther Califoria
Kaiser Permaete Isurace Compay (KPIC) Souther Califoria 1 For effective dates Jauary 1 December 1, 2015 Premier detal plas These detal isurace plas are uderwritte by Kaiser Permaete Isurace Compay, a subsidiary of Kaiser Foudatio Health Pla, Ic., ad admiistered by Delta Detal of Califoria. The KPIC Premier plas are ot iteded to satisfy the pediatric detal beefits. Pla C Pla D Pla E Pla E with Ortho 2 Limitatios Service Pla pays 3 Pla pays 3 Pla pays 3 Pla pays 3 No deductible applies to these procedures. Exam 100% 100% 100% 100% Twice a year Bitewig X-rays X-rays of the top ad bottom molars ad premolars to show decay betwee teeth or uder fillig 100% 100% 100% 100% Twice a year for childre through age 18, or oce a year for adults 19 ad over Other X-rays 80% 80% 80% 80% Full-mouth X-rays, sigle X-rays, ad paographic X-rays oce i ay five-year period Prophylaxis A professioal cleaig to remove plaque, calculus (mieralized plaque), ad stais to help prevet detal disease Fluoride treatmets A treatmet with a chemical compoud that prevets cavities ad makes the tooth surface stroger so the teeth ca resist decay Deductibles apply to procedures uder plas D, E, ad E with Orthodotics. Deductible 100% 100% 100% 100% Twice a year 100% 100% 100% 100% Oly for childre through age 18, twice a year No deductible $25 $25 $25 Per perso per year up to a family maximum of $75 per year Beefit maximum $500 $1,000 $1,000 $1,000 Beefit maximum represets the total amout paid by the pla per perso, per year. Palliative care Ay form of medical care or treatmet that cocetrates o reducig the severity of disease symptoms; the goal is to prevet ad relieve sufferig ad improve quality of life 80% 80% 80% 80% Usual, customary, ad reasoable Deture relies 80% 80% 80% Twice a year (limited to two upper, two lower, or ay combiatio) 4 Space maitaiers 100% 100% 100% 100% Usual, customary, ad reasoable Filligs 80% 80% 80% 80% Usual, customary, ad reasoable Stailess steel crows 80% 80% 80% 80% Primary teeth oly Edodotics A detal specialty cocered with treatmet of the root ad erve of the tooth Periodotics A detal specialty cocered with the treatmet of gums, tissue, ad boe that support the teeth 80% 80% 80% Usual, customary, ad reasoable 80% 80% 80% Usual, customary, ad reasoable Oral surgery 80% 80% 80% Usual, customary, ad reasoable Crows ad cast restoratios The artificial coverig of a tooth with metal, porcelai, or porcelai fused to metal; covers teeth that are weakeed by decay or severely damaged or chipped Prosthodotics A detal specialty cocered with restoratio ad/or replacemet of missig teeth with artificial materials Orthodotics A detal specialty cocered with straighteig or movig misaliged teeth ad/or jaws with braces ad/or surgery 50% 50% Icludes replacemets after five years, but oly if origially by KPIC detal pla 50% 50% Stadard removable prosthetic appliace (icludes replacemets after five years, but oly if origially by KPIC detal pla) 50% For eligible depedet childre through age 18, $1,500 lifetime maximum per isured (replacemet or repair of a orthodotic appliace paid for i part or i full by this pla is ot ). Mothly premiums Pla C Pla D Pla E Pla E Ortho 2 Employee $29.93 $42.30 $59.28 $60.53 Employee + spouse $61.36 $86.72 $121.53 $124.09 Employee + child(re) $62.85 $88.84 $124.49 $127.11 Family $99.37 $140.45 $196.82 $200.96 1 For the ZIP codes withi the Kaiser Permaete service area, detal rate area icludes Los Ageles (except ZIP codes 93243 ad 93560), Orage, Riverside (except ZIP code 92028 ad excludig Coachella Valley detal area), Sa Berardio (except ZIP codes 92252, 92256, 92268, 92277 78, ad 92284 86), ad Vetura couties (except ZIP code 93252); also icludes the followig ZIP code i Ker couty (93536) 2 Pla E with Orthodotics requires at least 10 subscribers. 3 Beefits payable will be based o the lesser of the usual, customary, ad reasoable fees or the fees actually charged. 4 Limitatio applies oly to Pla D. 2
Kaiser Permaete Isurace Compay (KPIC) Souther Califoria 1 For effective dates Jauary 1 December 1, 2015 PPO detal plas These detal isurace plas are uderwritte by Kaiser Permaete Isurace Compay, a subsidiary of Kaiser Foudatio Health Pla, Ic., ad admiistered by Delta Detal of Califoria. The KPIC PPO plas are ot iteded to satisfy the pediatric detal beefits. Service Pla pays 2 Pla pays (PPO (out of etwork) etwork) No deductible applies to these procedures. PPO D 1500 PPO E 1000 PPO E 1500 Limitatios Pla pays 2 (PPO etwork) Pla pays (out of etwork) Pla pays 2 (PPO etwork) Pla pays (out of etwork) Exam 100% 50% 100% 50% 100% 50% Twice a year Bitewig X-rays X-rays of the top ad bottom molars ad premolars to show decay betwee teeth or uder fillig 100% 50% 100% 50% 100% 50% Twice a year for childre through age 18, or oce a year for adults 19 ad over Other X-rays 80% 50% 80% 50% 80% 50%Full-mouth X-rays, sigle X-rays, ad paographic X-rays oce i ay five-year period Prophylaxis A professioal cleaig to remove plaque, calculus (mieralized plaque), ad stais to help prevet detal disease Fluoride treatmets A treatmet with a chemical compoud that prevets cavities ad makes the tooth surface stroger so the teeth ca resist decay Deductibles apply to all procedures below. 100% 50% 100% 50% 100% 50% Twice a year 100% 50% 100% 50% 100% 50% Oly for childre through age 18, twice a year Deductible $25 $50 $25 $50 $25 $50 Per perso per year up to a family maximum of $75 (i etwork) ad $150 (out of etwork) Beefit maximum $1,500 $1,500 $1,000 $1,000 $1,500 $1,500 Beefit maximum represets the total amout paid by the pla per perso, per year. Palliative care Ay form of medical care or treatmet that cocetrates o reducig the severity of disease symptoms; the goal is to prevet ad relieve sufferig ad improve quality of life 80% 50% 80% 50% 80% 50% Deture relies 80% 50% 80% 50% 80% 50% Twice a year Space maitaiers 100% 50% 100% 50% 100% 50% Filligs 80% 50% 80% 50% 80% 50% Stailess steel crows 80% 50% 80% 50% 80% 50% Primary teeth oly Edodotics A detal specialty cocered with treatmet of the root ad erve of the tooth 80% 50% 80% 50% 80% 50% Periodotics A detal specialty cocered with the treatmet of gums, tissue, ad boe that support the teeth 80% 50% 80% 50% 80% 50% Oral surgery 80% 50% 80% 50% 80% 50% Crows ad cast restoratios The artificial coverig of a tooth with metal, porcelai, or porcelai fused to metal; covers teeth that are weakeed by decay or severely damaged or chipped Prosthodotics A detal specialty cocered with restoratio ad/or replacemet of missig teeth with artificial materials Orthodotics A detal specialty cocered with straighteig or movig misaliged teeth ad/or jaws with braces ad/or surgery 50% 50% 50% 50% Icludes oe replacemet i ay five-year period, but oly if origially by KPIC detal pla 50% 50% 50% 50% Stadard removable prosthetic appliaces (icludes oe replacemet i ay five-year period, but oly if origially by KPIC detal pla) Mothly premiums PPO D 1500 PPO E 1000 PPO E 1500 Employee $36.25 $48.63 $51.06 Employee + spouse $74.31 $99.69 $104.67 Employee + child(re) $76.12 $102.12 $107.22 Family $120.34 $161.45 $169.51 1 For the ZIP codes withi the Kaiser Permaete service area, detal rate area icludes Los Ageles (except ZIP codes 93243 ad 93560), Orage, Riverside (except ZIP code 92028 ad excludig Coachella Valley detal area), Sa Berardio (except ZIP codes 92252, 92256, 92268, 92277 78, ad 92284 86), ad Vetura couties (except ZIP code 93252); also icludes the followig ZIP code i Ker couty (93536) 2 Beefits payable will be based o the maximum allowable charge. 3
Importat iformatio for the KPIC Premier ad KPIC PPO detal isurace plas The KPIC Premier ad KPIC PPO detal isurace plas are ot iteded to satisfy the pediatric detal beefits. The followig services are ot uder ay Kaiser Permaete Isurace Compay (KPIC) group detal isurace plas: Ay treatmet or procedure ot listed as Charges i excess of the maximum allowable charge Services for ijuries or coditios uder workers compesatio or employer s liability laws Cosmetic surgery, detistry, or services to correct hereditary, cogeital, or developmetal malformatios Restoratio of tooth structure or chewig surfaces for damages due to wear Prosthodotic services or procedures started prior to a perso s date of eligibility Prescribed drugs, premedicatio, or pai relievers Experimetal procedures Hospital costs or extra charges for hospital treatmet Aesthesia (except geeral aesthesia for oral surgery) Extra-oral grafts, implats, or implat removal Treatmet related to the temporomadibular joit (TMJ) Plaque-cotrol programs, oral hygiee, or dietary istructios Orthodotic treatmet, except for eligible depedet childre uder Pla E with Orthodotics Treatmet plas that are more expesive tha those customarily provided, or specialized techiques used istead of stadard procedures; for example, a precisio deture where a stadard deture would suffice Pit ad fissure sealats, except for first molars of childre through age 8 ad secod molars for childre through age 15. The molar must have o decay ad o restoratio, ad the occlusal surface must be itact. Coverage does ot iclude the repair or replacemet of a sealat o ay tooth withi three years of applicatio. Services provided to the perso by ay federal or state govermetal agecy or provided without cost to the perso by ay muicipality, couty, or other political subdivisio, except Medi-Cal beefits Charges by ay hospital or other surgical treatmet facility, or ay additioal fees charged by the detist for treatmet i ay such facility Implats (materials implated ito or o boe or soft tissue) or the repair or removal of implats Replacemet of existig restoratio for ay purposes other tha active tooth decay Itraveous sedatio, occlusal guards, or complete occlusal adjustmet Charges for replacemet or repair of a orthodotic appliace paid i part or i full by this program Hyposis Charges for completio of forms Charges for speech therapy Charges for lost or stole appliaces Services for which o charge is ormally made i the absece of isurace Predetermiatio of beefits is recommeded for services i excess of $300. This documet is ot iteded as a summary pla descriptio, or is it desiged to serve as the Certificate of Isurace or the Schedule of Coverage. It cotais oly a summary of beefits, exclusios, ad limitatios. If you have specific questios regardig beefit structure, limitatios, or exclusios, cosult the Certificate of Isurace ad the Schedule of Coverage or cotact Delta Detal s Customer Service Departmet at 1-888-335-8227, 8 a.m. to 5 p.m., Moday through Friday. For a list of i-etwork providers, cotact Delta Detal s Customer Service Departmet. This detal isurace pla is uderwritte by Kaiser Permaete Isurace Compay, a subsidiary of Kaiser Foudatio Health Pla, ad admiistered by Delta Detal of Califoria. 4
DeltaCare HMO Detal plas DeltaCare USA is uderwritte ad admiistered by Delta Detal of Califoria. Norther Califoria ad Souther Califoria For effective dates Jauary 1 December 1, 2015 Services DeltaCare 10A DeltaCare 13B Limitatios Prevetive care Periodic ad comprehesive oral evaluatio No cost No cost Twice a year Bitewig X-rays No cost No cost Twice a year for childre through age 18, or oce a year for adults 19 ad over Prophylaxis No cost No cost Twice a year Fluoride treatmets No cost No cost Oly for childre up to age 19, twice a year Space maitaiers $10 $50 Removable uilateral Periodotics Maiteace No cost $35 Twice a year Scalig ad root plaig No cost $50 Limited to four quadrats per year Surgery osseous (icludes flap etry ad closure) $175 $300 Four or more teeth per quadrat Restorative Filligs primary or permaet amalgam No cost No cost Four or more surfaces Composite crows resi-based No cost $55 Aterior Crow porcelai $195 $355 Ilay metallic No cost $145 Oe surface Edodotics Therapeutic pulpotomy No cost $25 Excludes fial restoratio Root amputatio No cost $70 Per root Root caal aterior $45 $95 Excludes fial restoratio Root caal molar $205 $335 Excludes fial restoratio Prosthodotics Complete deture $100 $285 The erollee must cotiue to be eligible ad the service must be provided at the cotract detist facility where the deture was origially delivered. Relie maxillary or madibular deture chairside No cost $50 Complete or partial Relie maxillary or madibular deture laboratory $35 $85 Complete or partial Oral ad maxillofacial surgery Extractio erupted tooth or exposed root No cost $5 Elevatio ad/or forceps removal Surgical removal of erupted tooth $15 $45 Complete or partial Orthodotics Comprehesive orthodotic child $1,700 $1,900 Child or adolescet to age 19 Comprehesive orthodotic adult $1,900 $2,100 Adults, icludig depedet adult childre Mothly premium rates for Souther Califoria Employee $17.86 $12.68 Subscriber Employee + spouse $34.11 $24.22 Subscriber ad spouse Employee + child(re) $47.50 $33.73 Subscriber ad child without spouse Family $65.54 $46.54 Subscriber, spouse, ad child Mothly premium rates for Norther Califoria Employee $20.65 $15.12 Subscriber Employee + spouse $39.44 $28.88 Subscriber ad spouse Employee + child(re) $54.92 $40.22 Subscriber ad child without spouse Family $75.78 $55.49 Subscriber, spouse, ad child Beefits listed above are oly a sample of provided services ad associated costs. Costs will vary. Please see your Evidece of Coverage for a comprehesive list of all services ad costs. DeltaCare beefits are oly whe performed by a i-etwork Califoria DeltaCare HMO provider. I Califoria, DeltaCare USA is uderwritte ad admiistered by Delta Detal of Califoria. The DeltaCare HMO plas are ot iteded to satisfy the pediatric detal beefits. 5
Exclusios of beefits for DeltaCare HMO Detal plas DeltaCare HMO detal isurace plas are ot iteded to satisfy the pediatric detal beefits. Exclusios 1. The DeltaCare HMO Detal pla is ot available for employees erolled i a PPO medical pla ad livig outside of Califoria. 2. Ay procedure that i the professioal opiio of the cotract detist: a. has poor progosis for a successful result ad reasoable logevity based o the coditio of the tooth or teeth ad/or surroudig structures, or b. is icosistet with geerally accepted stadards for detistry 3. Services solely for cosmetic purposes, with the exceptio of procedure D9972 (exteral bleachig, per arch), or for coditios that are a result of hereditary or developmetal defects, such as cleft palate, upper ad lower jaw malformatios, cogeitally missig teeth, ad teeth that are discolored or lackig eamel, except for the treatmet of ewbor childre with cogeital defects or birth abormalities 4. Porcelai crows, porcelai fused to metal, cast metal or resi with metal type crows, ad fixed partial detures (bridges) for childre uder 16 years of age 5. Lost or stole appliaces icludig, but ot limited to, full or partial detures, space maitaiers, crows, ad fixed partial detures (bridges) 6. Procedures, appliaces, or restoratio if the purpose is to chage vertical dimesio, or to diagose or treat abormal coditios of the temporomadibular joit (TMJ) 7. Precious metal for removable appliaces, metallic or permaet soft bases for complete detures, porcelai deture teeth, precisio abutmets for removable partials or fixed partial detures (overlays, implats, ad appliaces associated therewith), ad persoalizatio ad characterizatio of complete ad partial detures 8. Implat-supported detal appliaces ad attachmets; implat placemet, maiteace, or removal; ad all other services associated with a detal implat 9. Cosultatios for o beefits 10. Detal services received from ay detal facility other tha the assiged cotract detist, a preauthorized detal specialist, or a cotract orthodotist except for Emergecy Services as described i the cotract ad/or Evidece of Coverage 11. All related fees for admissio, use, or stays i a hospital, outpatiet surgery ceter, exteded care facility, or other similar care facility 12. Prescriptio drugs 13. Detal expeses icurred i coectio with ay detal or orthodotic procedure started before the erollee s eligibility with the DeltaCare USA program. Examples iclude: teeth prepared for crows, root caals i progress, full or partial detures for which a impressio has bee take, ad orthodotics uless qualified for the orthodotic treatmet i progress provisio 14. Lost, stole, or broke orthodotic appliaces 15. Chages i orthodotic treatmet ecessitated by accidet of ay kid 16. Myofuctioal ad parafuctioal appliaces ad/or therapies 17. Composite or ceramic brackets, ligual adaptatio of orthodotic bads, ad other specialized or cosmetic alteratives to stadard fixed ad removable orthodotic appliaces 18. Treatmet or appliaces that are provided by a detist whose practice specializes i prosthodotic services For additioal beefit iformatio or a directory of Delta detists, please call Delta Detal at 1-800-422-4234 or visit deltadetalis.com. Small Busiess 60243419 Jauary December 2015 6