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The dentists are screened to ensure that the
plan standards of quality, access and safety are maintained. The
network is composed of established dental professionals. This dental
insurance plan provides coverage for one year. To enroll yourself or
other eligible dependents you pay the annual premium and a one time
enrollment fee. You choose your dentist from the online dentist
directory during enrollment. Coverage is effective for 12 months and
renewal is required to continue coverage.
Delta Dental must receive the enrollment materials by the 20th day of
the month for coverage to be effective the first day of the following
month. If Delta Dental receives the enrollment materials after the
20th day of the month, coverage will become effective the first day of
the second month. This Enrollment and Payment Authorization Form and
your check or money order, if applicable, must be received by the 20th
day of the month for your coverage to be effective on the first day of
the following month.
Disclosure Form/Contract
Detailed disclosure of plan co-payments, limitations and exclusions.
• See the Delta Dental insurance disclosure form -- click on the
"Download Schedule of Benefits" image above.
A full refund of Premium, including the one
time enrollment fee, is available if the written request for
refund is made within the first month of the Contract Term.
Thereafter, requests for Premium refund will be pro-rated based
upon the number of months remaining in the Contract Term subject
to the following conditions:
1.The one-time enrollment fee is not refundable after the first
month of coverage.
2.You, or your covered dependents, have not received any
Benefits under the DeltaCare® USA program.
3.There is at least one month remaining in the Contract Term.
4.Coverage is based on a full calendar month. There are no
partial month refunds.
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Coverage for an enrollee will terminate as
of the date enrollment is cancelled under the terms of the Disclosure
Form/Contract. However, we will continue to provide benefits for
completion of any treatment in progress (less any applicable
co-payment). Cancellation of enrollment of a primary enrollee will
automatically cancel the enrollment of a dependent enrollee. Any
cancellation is subject to the written notification requirements set
forth in the Disclosure Form/Contract. If coverage is voluntarily
discontinued, you and your eligible dependents may not re-enroll
during the 12-month period immediately following the voluntary
termination.
DeltaCare® USA is underwritten in these states by these entities: AL
Alpha Dental of Alabama, Inc.; AZ Alpha Dental of Arizona, Inc.; CA
Delta Dental of California; AR, CO, IA, ME, MI, OK, OR, RI, SC, SD,
WA, WI, WY Dentegra Insurance Company; NH and VT - Dentegra Insurance
Company of New England; AK, CT, DE, FL, GA, KS, LA, MS, MT, TN, WV and
Washington, D.C. Delta Dental Insurance Company; HI, ID, IL, IN, KY,
MD, MO, NJ, OH, TX Alpha Dental Programs, Inc.; NV Alpha Dental of
Nevada, Inc.; UT Alpha Dental of Utah, Inc.; NM Alpha Dental of New
Mexico, Inc.; NY Delta Dental of New York; PA Delta Dental of
Pennsylvania. Delta Dental Insurance Company acts as the DeltaCare USA
administrator in all these states, except CA. These companies are
financially responsible for their own products.
You must receive treatment from your selected network facility in
order to receive benefits. Your facility may refer you to a network
specialist for specialty care treatment. Specialty care treatment
received from a dental school clinic may be provided by a dental
provider, a dental student, a clinician or dental instructor.
You will receive a list of up to 100 DeltaCare USA network offices
nearest to you. The number of dental providers displayed depends on
the address and availability of dental providers in that area. After
making a selection from the results list, note the office number to
include on your enrollment application. Once you are eligible on the
plan, you will receive an identification card and an Evidence of
Coverage booklet describing your benefits.
You can make an appointment once you have received confirmation of
your enrollment.
• If you are currently enrolled in the DeltaCare USA program, you may
transfer to another facility by completing the online customer service
request form.
• Delta Dental must receive the DeltaCare USA enrollment materials
and/or facility change request by the 20th day of the month for
coverage to be effective the 1st day of the following month.
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