Delta Dental Insurance Company: Individual Dental Plan: New York



	Required Disclosure Statement Disclosure Form / Contract ("Contract") What is the DeltaCare USA Individual / Family Dental Program? How to use the Program / Choice of Contract Dentist Who is eligible for coverage? How do I enroll? What will my Effective Date be?

DELTA DENTAL OF NEW YORK, INC.

One Delta Drive
Mechanicsburg, PA 17055-6999

DENTAL INSURANCE COVERAGE
REQUIRED DISCLOSURE STATEMENT

This contract provides DENTAL insurance only and pays for dental care subject to Copayments paid by you. Applicable Copayments are listed in Schedule A of the attached contract.

The Disclosure Form provides a very brief description of the important features of your contract. The contract itself sets forth the rights and obligations of both you and the insurance company. It is therefore important that you READ THE ATTACHED CONTRACT carefully.

Covered Benefits

Diagnostic	Copayment
Oral Evaluations	No Cost
Bitewing x-rays, - 1 series every 6 months	No Cost
Office Visit	$5
Preventive	Copayment
Prophylaxis cleaning, - 1 per 6 month period	$20
Topical application of fluoride - to age 19, 1 per 6 month period	$25
Sealant - per tooth - limited to permanent molars through age 15	$20
Space Maintainer - fixed-bilateral	$150
Restorative	Copayment
Amalgam filling - one surface, primary or permanent	$37
Resin-based composite - one surface, anterior	$65
Inlay - metallic - one surface	$260
Onlay - metallic -two surfaces	$270
Crown - porcelain fused to noble metal	$325
Recement crown	$20
Endodontics	Copayment
Pulp cap - direct (excluding final restoration)	$25
Root Canal - anterior (excluding final restoration)	$250
Therapeutic pulpotomy (excluding final restoration)	$45
Retrograde filling - per root	$65
Periodontics	Copayment
Gingivectomy or gingivoplasty	$260
Periodontal scaling and root planing, limited to 4 quadrants during any 12 consecutive months	$80
Periodontal maintenance limited to 1 treatment each 6 month period	$50
Prosthodontics (removable & fixed)	Copayment
Complete denture - maxillary / mandibular	$450
Maxillary / mandibular partial denture- resin base (including any conventional clasps, rests and teeth)	$300
Adjustments dentures / partials	$20
Repair broken complete denture base	$50
Relines (chairside)	$50
Pontic - cast noble metal	$325
Crown - full cast noble metal	$325
Stress breaker	$50
Oral and Maxillofacial Surgery	Copayment
Single tooth	$40
Removal of impacted tooth - partially bony	$190
Surgical removal of residual tooth roots (cutting procedure)	$75
Incision and drainage of abscess - intraoral soft tissue	$35
Orthodontics	Copayment
Start-up fee	$200
Comprehensive orthodontic treatment of the transitional (or adolescent dentition - child or adolescent to age 19	$2,300 *
Comprehensive orthodontic treatment of the adult dentition - adults, including dependent adult children covered as full-time students	$2,500 *
Orthodontic retention (removal of appliances, construction and placement of retainers)	$250 **
* Covers up to 24 months of treatment
** Covers up to 24 months of retention
Adjunctive General Services	Copayment
Palliative (emergency) treatment of dental pain - minor procedure	$35
Regional block anesthesia	No Cost
Office visit - after regularly scheduled hours	$50
Failed Appointments without 24 hour notice - per 15 minutes of appointment	$15

Limitations and Exclusions - This is an abbreviated listing for informational purposes only. Consult the contract for a complete listing of Limitations and Exclusions.
1. Coverage for the placement of a fixed partial denture ("bridge") is limited to:
  1. The initial placement of a bridge when all the following conditions are present:
    1. a single permanent tooth requires prosthetic replacement;
    2. the abutment teeth can adequately support and retain a new bridge;
    3. the missing tooth cannot be replaced by adding a prosthetic tooth to a serviceable existing removable partial denture;
  2. The replacement of an existing bridge that is not serviceable due to decay, fracture or other non-cosmetic defect, if:
    1. the existing bridge is at least five years old; and - the same abutment teeth can adequately support and retain a new bridge; and
    2. no other missing teeth in the same arch require prosthetic replacement;
2. Coverage for a new removable partial or complete denture is limited to:
  1. The initial placement of removable partial or complete denture in an arch when:
    1. one or more permanent teeth require prosthetic replacement; and
    2. the missing tooth/teeth cannot be replaced by adding a prosthetic tooth to a serviceable existing removable partial denture; and
    3. (for partial dentures only) there are suitable abutment teeth to retain and support a removable partial denture;
  2. The replacement of an existing removable partial or complete denture with non-cosmetic defect(s) that cause the denture to be non-serviceable if:
    1. the existing removable denture is at least five years old; and
    2. the existing removable denture cannot be made serviceable by adjustment, repair, relining or rebasing;
3. Benefits provided by a pediatric dentist are limited to children through age seven following an attempt by the assigned contract dentist to treat the child and upon preauthorization by the administrator, less applicable copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis.
4. Soft tissue management programs include but are not limited to periodontal pocket charting, root planing, scaling, curettage, oral hygiene instruction, periodontal maintenance and/or prophylaxis. If you decline non-covered services within a soft tissue management program, it does not eliminate or alter the benefit for covered services;
5. 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;
6. 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:
  1. will not be entitled to a refund of any amounts previously paid, and
  2. 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;
7. 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;
8. Dental conditions arising out of and due to Enrollee's employment for which Worker's Compensation is paid. Services that are provided to the Enrollee by state government or agency thereof, or are provided without cost to the Enrollee by any municipality, county or other subdivision;
9. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility;
10. Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges);
11. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage;
12. Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension;
13. Dispensing of drugs not normally utilized in the delivery of dental services;
14. Dental services received from any dental facility other than the assigned Contract Dentist, including the services of a dental specialist, unless expressly preauthorized in writing by us or as cited under Emergency Services. To obtain written authorization, you should call the Customer Relations department at 800- 422-4234;
15. Extraction/removal of an erupted, partially erupted or impacted tooth:
  1. Solely for orthodontic purposes;
  2. When the tooth exhibits no signs or symptoms of infection, cystic degeneration, fracture, caries and/or having caused damage to an adjacent tooth; or
  3. When the extraction or removal would be inconsistent with generally accepted professional standards;
16. Treatment required by reason of war declared or undeclared;
17. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.
18. Lost, stolen or broken orthodontic appliances;
19. Changes in treatment necessitated by lack of Enrollee cooperation;
20. Surgical procedures incidental to orthodontic treatment;
21. Treatment related to temporomandibular joint disturbances which are medical in nature;
22. Restorative work caused by orthodontic treatment;
23. Extractions solely for the purpose of orthodontics.
The expected benefit ratio for this contract is 60.5%. This ratio is the portion of future premiums that the Company expects to return as benefits, when averaged over all people with this program.