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ORTHODONTIC LIMITATIONS |
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The DeltaCare USA program provides coverage for orthodontic treatment plans provided through Contract Orthodontists. Start-up fees, retention fees, and the cost to the Enrollee for the treatment plan are listed in Schedule A, Description of Benefits and Copayments and are subject to the following:
- Orthodontic treatment must be provided by the Contract Orthodontist;
- Orthodontic Copayments are listed on Schedule A, for comprehensive orthodontic treatment. Additional fees will be charged for start-up and retention;
- Benefits cover 24 months of active comprehensive orthodontic treatment, including initial banding, de-banding and any commonly used appliances such as headgear;
- Following benefited comprehensive orthodontic treatment, retention is covered up to a maximum of 24 months. Retention includes the initial construction, placement and adjustment to removable retainers and office visits;
- Treatment plans extending beyond 24 months of active comprehensive orthodontic treatment, or 24 months of retention, will be subject to a monthly office visit fee to the Enrollee not to exceed $125.00 per month;
- Should an Enrollee's coverage be cancelled or terminated for any reason, and at the time of cancellation or termination the Enrollee is receiving orthodontic treatment, the Enrollee will be solely responsible for payment for treatment provided after cancellation or termination. In this event the Enrollee's obligation shall increase to a maximum of the Contract Orthodontist's usual fee at the beginning of treatment. The Contract Orthodontist will prorate the amount over the number of months remaining in the initial 24 months of treatment. The Enrollee will make payments based on an arrangement with the Contract Orthodontist;
- Three recementations or replacements of a bracket/band on the same tooth or a total of five- rebracketings/rebandings on different teeth during the covered course of treatment are Benefits. If any additional recementations or replacements of brackets/bands are performed, the Enrollee is responsible for the cost at the Contract Orthodontist's usual fee;
- The Copayment is payable to the Contract Orthodontist who initiates banding in a course of orthodontic treatment. If, after banding has been initiated, the Enrollee changes to another Contract Orthodontist to continue orthodontic treatment, the Enrollee:
- will not be entitled to a refund of any amounts previously paid, and
- will be responsible for all payments, up to and including the full Copayment, that are required by the new Contract Orthodontist for completion of the orthodontic treatment;
- Coverage and treatment under this Program are conditioned on patients following the treatment plan recommended by their Contract Orthodontist. Failure to follow the instructions of the Orthodontist can compromise the health of teeth and/or gums, which may necessitate discontinuation of treatment. Patients who are required to restart their orthodontic treatment because of non-compliance with the treatment plan will be subject again to all applicable copayments.
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