Delta Dental of New Mexico

… administering the dental plan for

State of New MexicoGeneral Services DepartmentRisk Management Division

Improved Oral Health =Improved Overall Health

“Oral Health is Integral To Overall Health.”

“… studies have demonstrated an association between periodontal diseases and diabetes, cardiovascular disease, stroke, and adverse pregnancy outcomes.”

From the May, 2000 Surgeon General’s Report

GSD/RMD Dental Plan

Calendar Year Deductibles:

• Do not apply to Diagnostic & Preventive Care Services or to Orthodontic Services

$ 50 per enrolled person $150 aggregate per family

GSD/RMD Dental Plan

GSD/RMD Dental Plan

Calendar Year Maximum *:

$1750 per enrolled person

* A separate lifetime maximumapplies to Orthodontic Services

GSD/RMD Dental PlanProvider Network

PPONEW MEXICO SUBSCRIBERS ANDDEPENDENTS

Over 760 PPONEW MEXICOdentist locations statewide

Choose any in-networkdentist statewide

Dentists accept PPONEWMEXICO

dentist fees (no balance billing)

Pay only coinsurance and deductible (if any)

for covered services

On-line dentist searchdeltadentalnm.com

Each family member may choose a different dentist

Benefit In-Network Out-of-Network

Diagnostic and Preventive Services

Plan Pays 100%no deductibleYou Pay: 0%

Plan Pays 100% *no deductible

You Pay: Any Amount Balance Billed *

Oral Examinations - twice in a calendar year Cleanings - twice in a calendar year X-rays: Full mouth -1 in 5 years / Bitewing - 2 in a calendar year Fluoride Application - through age 18, twice per calendar year Emergency Treatment Space Maintainers - through age 18, 5 year limitation Sealants - through age 15, permanent molars only, 3 year limit

GSD/RMD Dental PlanBenefits Overview

* The approved fees applicable to non-participating providers are less than those applicable toPPONew Mexico dentists. Because non-network providers may balance bill patients for amounts above approved

fees, and because some benefit levels are lower when services are received from non-participating providers,out-of-pocket costs may be significantly higher if services are received out-of-network.

Benefit In-Network Out-of-Network

Basic ServicesPlan Pays 80%

deductible appliesYou Pay: 20%

Plan Pays 55% *deductible applies

You Pay: 45% plus Balance Billing *

Amalgam or composite resin fillings Extractions – surgical/non-surgical Periodontics - non-surgical / surgical treatment of gum disease Endodontics - pulp therapy and root canal filling Repair of implants, dentures and bridgework General Anesthesia - intravenous sedation & general anesthesia Oral Surgery Stainless steel crowns

GSD/RMD Dental ProgramBenefits Overview

* The approved fees applicable to non-participating providers are less than those applicable toPPONew Mexico dentists. Because non-network providers may balance bill patients for amounts above

approved fees, and because these benefit levels are lower than those applicable in-network,out-of-pocket costs may be significantly higher if services are received out-of-network.

Benefit In-Network Out-of-Network

Major ServicesPlan Pays 60%*

deductible appliesYou Pay: 40%*

Plan Pays 35% *deductible applies

You Pay: 65% plus Balance Billing *

Inlays, Onlays, Crowns and Cast Restorations – when teeth cannotbe restored with amalgam or composite resin restorations

Prosthodontics – Bridges, partials or complete dentures

Implants – specified services and related prosthodontics, subject to clinical review/approval

GSD/RMD Dental ProgramBenefits Overview

* The approved fees applicable to non-participating providers are less than those applicable toPPONew Mexico dentists. Because non-network providers may balance bill patients for amounts above

approved fees, and because these benefit levels are lower than those applicable in-network,out-of-pocket costs may be significantly higher if services are received out-of-network.

Benefit In-Network Out-of-NetworkORTHODONTIC SERVICES

No deductibleChildren -- up to 18th birthday

Plan Pays 75% up to a $2000 lifetime maximum

Adults -- age18 and over

Plan Pays 60%up to a $1750 lifetime maximum

GSD/RMD Dental ProgramBenefits Overview

There are Limitations and Exclusions not covered in this Benefits Overview.Refer to the Dental Benefit Handbook for complete coverage information.

Patient Disclosure –You’re entitled to it!

PPONEW MEXICO Dentist’s Guarantee

Upon request, a pre-treatment cost range will be provided by your dentist

Pre-determination of benefitsis available from Delta Dental - recommended (not required) for expensive procedures

You and your dentist agree

GSD/RMD Dental PlanPatient Disclosure

GSD/RMD Dental Plan

Verify eligibility Review benefit information Review Calendar Year

Maximum and Deductible Information

Check on a specific claim Print a personalized ID card Review oral health information

24/7 Information Access with the Delta Dental Online Consumer Toolkit!

deltadentalnm.com

GSD/RMD Dental Plan

All dental plan claims and administration services provided in New Mexico

Trained Benefit Representatives

• Available Monday – Friday 8:00am-4:30pm

• Albuquerque 505-855-7111

• Toll free 1-877-395-9420

• Over 95% of calls answeredin fewer than 45 seconds

GSD/RMD Dental Plan

Questions?