Smile guide

Dental made simple.

Your Preferred Dental Organization Member Handbook & Dentist Directory

For active employees and retirees

State of Tennessee

Thank you for joining the State of Tennessee’s Preferred Dental Organization option!

Good health starts with a healthy smile

There is a direct connection between a healthy mouth and a healthy body. More than 120 signs and symptoms of diseases like cancer, diabetes, and heart disease can appear in your mouth and can be spotted by your dentist.1

Also, visiting the dentist for cleanings and taking care of your mouth can help you better manage some of these same diseases. If you have certain health conditions, along with periodontal disease, you may be able to get additional cleanings each year. Just check with your dentist!

Finally, nearly 37,000 Americans are diagnosed with oral cancer each year, and the five-year survival rate is only 55 percent. This can jump to almost 90 percent when the cancer is diagnosed in early stages.2

Visiting your dentist really could be a life saver!

Dental Makes a Difference

Our secure, online Consumer Toolkit allows you to:

u Check benefit eligibilityu Print an ID cardu Sign up for paperless Explanation of Benefits (EOB)u Find current benefit informationu Review claimsu Learn more about oral health and wellnessu And more!

Go to www.DeltaDentalTN.com/statetn and click on ‘Consumer Toolkit.’ Click on ‘Register Now’ to sign up for the first time.

Your Benefits, 24/7

Want to know how much a procedure will cost? Want to make sure a service is covered under your plan? Request a predetermination (also called a “pre-estimate”).

Dentists can send a request to us, and we’ll let them know if a service is covered, how much it may cost, and what you may have to pay. These amounts may not be exact, but they will give you a good idea of what to expect.

No Surprises!

Choosing a dentist from the Delta Dental PPO℠ network will help you save the most money and get the most from your benefits, but you have the option to visit any licensed dentist.

Go to www.DeltaDentalTN.com/statetn and click on ‘Find a Dentist.’

Find a Dentist

1) Online Go to www.DeltaDentalTN.com/statetn for information about your plan on a site custom-built for you. You can also log in to the Consumer Toolkit from the site to look up your personal benefit information.

2) PhoneCall us at (800) 223-3104. Customer Service Representatives are available Monday through Friday, 7:00 a.m. to 5:00 p.m. CST. Our automated inquiry system, DASI, is available 24 hours a day, 7 days a week. With DASI, you can find a dentist, verify benefits, check claim and predetermination status, and more.

3) Dentist Talk to your dentist to determine if he or she is in the Delta Dental network and to request predeterminations so you will know if recommended services are covered benefits.

Questions Answered 3 Ways

1 Little, James W., Falace, Donald A., Miller, Craig S., & Rhodus, Nelson L. (2008). Dental Management of the Medically Compromised Patient (7th ed.). St. Louis, MO: Mosby Elsevier. 2 The Oral Cancer Foundation. 10 Aug 2011. http://oralcancerfoundation.org/

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Benefit Summary

Waiting Periods: Waiting periods begin on your effective date.

*Maximum Plan Allowance (MPA) – You are not responsible for charges exceeding the MPA if you go to a participating Delta Dental PPOSM dentist. You are responsible for charges exceeding the MPA if you go to a non-participating dentist. The MPA charges are based on fees charged in your geographic area.

If you drop your coverage while eligible, you cannot re-enroll in the plan until the next annual enrollment transfer period following 12 consecutive months without coverage, unless you have a life status change.

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State of Tennessee’s PDO Option Plan

ACTIVE EMPLOYEE RATES RETIREE RATES Employee Only . . . . . . . . . $20.46 RetireeOnly . . . . . . . . . . $26.41 Employee + Spouse . . . . . $38.69 Retiree+Spouse . . . . . . $49.96 Employee + Child(ren) . . . $47.03 Retiree+Child(ren) . . . . $60.73 Employee+Family . . . . . . $75.71 Retiree+Family . . . . . . . $97.76

Calendar Year Maximum amount per person per year for all expenses from in-network and out-of-network providers combined.

Lifetime Orthodontics Maximum amount per person per lifetime for all expenses from in-network and out-of-network providers combined.

Annual Deductible Deductible does not apply to Diagnostic and Preventive Services

Diagnostic and Preventive Services • Oralexaminations–2inacalendaryear • Prophylaxis(cleanings)–2inacalendaryear • Bitewingx-rays–1setin2yearsforadults;18monthsfor ages12to18;acalendaryearforageslessthan12. • Sealantstoage17 • Fluoridetreatmenttoage14 • Spacemaintainerstoage14 • Evidence-basedbenefits(upto4cleaningspercalendaryearfor certain members with high-risk health conditions)

Basic Services • Restorative(fillings) • X-rays • Simpleextractions

Major Services • Denturerepair • Denturerebase&reline • Endodontics(rootcanaltherapy) • Oralsurgery(extractionsincludingsurgicalremovalofteeth) • Periodontics(treatmentofgumsandbonessupportingteeth) • Implants12-month waiting period • Bridges(fixedandremovable)12-month waiting period • Partialdentures12-month waiting period • Fulldentures12-month waiting period • Crownsandcastrestorations12-month waiting period

Orthodontic Services 12-month waiting period • Fordependentstoage19

Delta Dental Out of PPO Network Network Benefits Benefits

$1500

$1250

No Deductibles $100 Per Person $300PerFamily

100%* 80%*

80%* 60%*

50%* 50%*

50%* 50%*

Frequently Asked Questions (FAQs) Q. Who Is Eligible For the PDO Plan? A. You, your spouse and eligible dependents under the

age of 26 can get dental coverage under this plan. ReviewacopyoftheStateofTennesseeEligibilityandEnrollmentGuidetoseeifyourdependentiseligible. You can get a copy of this guide from your agency benefits coordinator.

Q. What Dentists Can I Visit With This Plan?

A. You may choose any dentist with this plan. It is best to visit a dentist in Delta Dental’s PPO network. Here are some reasons why:

•In-NetworkBenefits.Youwillsavethemostmoney and get the most from this plan when you visit a dentist in the Delta Dental PPO network.

•ADeltaDentalPPODentistwillfilloutandsubmitclaim forms at no charge to you. Dentists who are notinthePPOnetworkmayrequireyoutofilloutforms or pay a service charge.

•DeltaDentalpaysdentistsinthePPOnetworkan agreed upon amount known as the maximum plan allowance. You will only have to pay your co-insurance amount if you see a Delta Dental PPO Dentist. That means you are not responsible for charges that exceed the maximum plan allowance. There is no deductible when you visit a Delta Dental PPO Dentist.

•DeltaDentalPPODentistswillnotchargeyoumore than your co-insurance amount. You do not have to pay the whole bill and wait for reimbursement.

•AdentistoutsidetheDeltaDentalPPOnetworkmay charge more than the maximum plan allowance. If you see a dentist who charges more than the maximum plan allowance, you have to pay the difference between the maximum plan allowance and the dentist’s fees,plusyourdeductibleand/orco-insurance.You may also have to pay the entire bill in advance and wait for reimbursement.

Q. Where Do I Get Answers To Questions About Dentists or Claims?

A. There are many ways to find answers to your questionsaboutdentistsandclaims.

Visit our Web site at www.DeltaDentalTn.com/statetn. There you can:

• Findoutifyourcurrentdentistisin the Delta Dental PPO network

• Viewyourbenefits

• PrintanIDcard

• Checkeligibility

• Checkclaimsstatus

Contact Us By Phone Call us at (800) 223-3104. Our automated phone

systemisavailabletoquicklyansweryourquestions24hoursaday,sevendaysaweek.

Should you need more help, our Customer ServiceRepresentativescanansweryourquestionsMondaythroughFridayfrom7a.m. to 5 p.m. Central.

Talk To Your Dentist Talk to your dentist and ask if he or she is

in the Delta Dental PPO network.

Q. How Do I Start Receiving Treatment? A. On or after your effective date of coverage, you

may call your dentist and make an appointment.

If your dentist is in the Delta Dental PPO network, he or she will complete and submit a claim for you at no charge.

If you go to a dentist that is not in our PPO network, you may have to submit your claim to:

Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228

Q. How Do I Pre-Determine My Benefits? A. You may want to know how much your dental work

is going to cost before treatment. Ask your dentist torequestapre-determination.Apre-determinationwill tell you how much the services will cost. It will also tell you how much you will have to pay. Pre-determinationsarenotrequiredandarenot a guarantee of benefits.

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Benefit Summary

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$27.20$51.46$62.55$100.69

$21.07$39.85$48.44$77.98

A. You, your spouse and eligible dependents under the age of 26 can get dental coverage under this plan. Review a copy of the State of Tennessee Eligibility and Enrollment Guide to see if your dependent is eligible. You can get a copy of this guide from your agency benefits coordinator.

Q. Who Is Eligible For the PDO Plan?

A. Yes. Ask your dentist to request a predetermination, which will tell you if a service is covered, how much it may cost, and what your portion may be. Predeterminations are not required and are not a guarantee of benefits.

Q. What is Balance Billing?

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Frequently Asked Questions (FAQs)

A. You are free to choose any licensed dentist, however it’s best to visit a Delta Dental PPO℠ dentist. Here’s why:

u In-Network Benefits: You will save the most money and get the most from this plan when you visit a Delta Dental PPO℠dentist.

u No Paperwork: A PPO network dentist will fill out and submit claim forms at no charge to you. Dentists who are not in the PPO network may require you to fill out forms or pay a service charge.

u No Balance Billing: Dentists in the PPO network agree to a cap on charges for services called the Maximum Plan Allowance (MPA). If you see a PPO dentist, you will only have to pay your co-insurance amount (there is no deductible when you see a PPO dentist). A non-network dentist has not agreed to the MPA, so you may have to pay the difference between what the dentist charges and what Delta Dental will pay.

u No Waiting for Reimbursement: PPO dentists will not charge you more than your co-insurance amount, and you won’t have to pay the whole bill and wait for reimbursement.

Q. What Dentists Can I Visit With This Plan?

A. On or after your effective date of coverage, call your dentist and make an appointment. If your dentist is in the Delta Dental PPO network, he or she will complete and submit a claim for you at no charge.

If you go to a dentist that is not in our PPO network, you may have to submit your claim to:

Delta Dental of Tennessee | 240 Venture CircleNashville, TN 37228

Q. How Do I Start Receiving Treatment?

Q. Can I find out how much a procedure will cost?

A. The dentists in the Delta Dental PPO℠network have agreed to accept a maximum fee for covered services called the Maximum Plan Allowance (MPA). PPO network dentists agree to accept the MPA as full payment and will not bill you for any fees above the MPA.

Dentists outside the PPO network have not agreed to the maximum fees. You may have to pay the difference between what the dentist charges and what Delta Dental will pay. This is balance billing. You will also have to pay your deductible and/or co-insurance.

Delta Dental “Safety Net”—You will save the most money by visiting a dentist in the Delta Dental PPO network, but you also have the option to see a Delta Dental Premier® dentist. Premier dentists have also agreed to an MPA (although it may be higher than the MPA for PPO dentists) so your out-of-pocket costs may be a bit higher, but you will not be balance billed like you would at a non–network dentist.

To find out if your dentist is a Delta Dental Premier dentist, visit our website at www.DeltaDentalTN.com/statetn or call your dentist’s office.

u Fees associated with instruction on proper oral hygiene and diet, treatment for drugs or medication, unproven treatments, conscious sedation and grafting of tissues formed outside the mouth to oral tissues.

u Charges from a hospital or other surgical treatment facility. Also includes dentist fees for treatment at these facilities.

u Treatment for the jaw joint or myofacial pain dysfunction.

u General Anesthesia or I.V. Sedation is only covered when given by a licensed DENTIST. The Anesthesia or Sedation must be given in a dental office and must be used for a covered procedure or when medically necessary because of concurrent medical conditions.

u The original placement of a denture that replaces natural teeth already missing when the person’s coverage begins.

u Services by a dentist beyond the scope of his or her license.

u Dental services for which the member is not charged.

A. If you are covered by two or more dental plans—usually because both you and your spouse receive coverage through work—your coverage will be coordinated. Your benefits will be handled by your “primary carrier,” or the one that lists your name as the primary member. Benefits will also be coordinated for your dependents that are covered under your plan and are also covered under another dental plan.

The goal of coordinating benefits is to make sure the cost of the dental procedure is covered within the scope of the plans without exceeding the amount of the actual bill.

For children covered by both parents’ (or guardians’) dental plans, the primary carrier is determined by the “birthday rule.” The plan that covers the parent or guardian whose birthday comes first in the calendar year will be considered the primary carrier.

Frequently Asked Questions (FAQs)

A. Delta Dental of Tennessee does not pay benefits for the following:

u Treatment for anything that would be covered by Workers Compensation or Employer Liability Laws.

u Free services from any federal, state, or local agency. Depending on state law, this may not apply.

u Services performed for looks rather than health, such as teeth whitening.

u Services for hereditary or developmental malformations, such as cleft palate and upper and lower jaw malformations. If Orthodontic Benefits are provided, some of these services may be covered.

u Treatment needed for wear on the teeth, such as erosion due to teeth grinding.

u Treatment to rebuild or maintain chewing surfaces when teeth are out of alignment, or treatment to stabilize teeth.

Q. What Is Not Covered?

Q. What If My Family Is Covered By Two Dental Programs (Dual Coverage)?

While this brochure highlights some of the features of our plan, this is not a Certificate of Coverage (COC). You will receive (or have already received if currently enrolled) a COC that has complete details about your dental plan.

You may also review your COC online at www.DeltaDentalTN.com/statetn

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PPO Directory

This is a directory of licensed Tennessee dentists who have signed contracts to provide professional services under Delta Dental. It is not a recommendation that a particular dentist should be consulted for professional care. Every effort has been made to prepare this list accurately, but Delta Dental assumes no responsibility for possible mistakes or omissions. It’s also possible that the dentists in this directory may not participate in our network for each location listed. We strongly recommend that you ask your prospective dentist about his or her current status with Delta Dental, confirm the dentists’ status through our online directory (www.DeltaDentalTN.com/statetn), or call Customer Service at (800) 223-3104 before visiting a dentist.