Dental Plan

Medicare-Eligible Members

Delta Dental of Missouri offers dental benefits through their nationwide networks. These benefits include preventive services, basic restorative services, and major restorative services.

You may select the dentist of your choice. Using a network Delta Dental PPO™ or Delta Dental Premier® dentist provides you the best benefit and savings. You may go to a non-network provider, however, your out-of-pocket costs will likely be higher. While network dentists are paid directly by Delta Dental for their services, a non-network dentist may require that you make full payment at the time of service and file the claim for reimbursement. They may also bill you the difference between the allowed amount and the full retail cost of their service.

The annual maximum benefit per individual is $2,000. The annual deductible per individual is $50.

Retirees who are not enrolled in dental coverage at retirement are not eligible to enroll later.

Service Type	Description	You Will Owe
Preventive (Type A) Services do not count towards your annual maximum	Oral exam – two per calendar year Cleaning – two per calendar year Bitewing x-rays – one set every calendar year Topical fluoride – once every calendar year Sealants – once every 5 calendar years Emergency palliative treatment Problem focused exams – 2 every calendar year	No deductible applies Network – You owe nothing more Non-Network – You may be balance billed any difference between allowed amount and retail cost
Basic Restorative (Type B)	Fillings Simple extractions Full mouth x-rays – once every 5 calendar years Periapical x-rays – as required Space maintainers – once every 5 calendar years	Deductible applies, plus you owe: Network – 20% coinsurance Non-Network – 20% coinsurance and any difference between allowed amount and retail cost
Major Restorative (Type C) 12-month waiting period. Waiting period will be waived for all enrollees with proof of 12 months of continuous dental coverage for major services immediately prior to the effective date of coverage in MCHCP’s Dental Plan.	Oral surgery & surgical extractions Implants – once every 7 calendar years Endodontics / root canal therapy Crowns – once every 7 calendar years Dentures & bridges – once every 7 calendar years Periodontics – surgical & non-surgical	Deductible applies, plus you owe: Network – 50% coinsurance Non-Network – 50% coinsurance and any difference between allowed amount and retail cost

Service Type

Description

You Will Owe

Preventive (Type A)
Services do not count towards your annual maximum

Oral exam – two per calendar year
Cleaning – two per calendar year
Bitewing x-rays – one set every calendar year
Topical fluoride – once every calendar year
Sealants – once every 5 calendar years
Emergency palliative treatment
Problem focused exams – 2 every calendar year

No deductible applies

Network – You owe nothing more
Non-Network – You may be balance billed any difference between allowed amount and retail cost

Basic Restorative (Type B)

Fillings
Simple extractions
Full mouth x-rays – once every 5 calendar years
Periapical x-rays – as required
Space maintainers – once every 5 calendar years

Deductible applies, plus you owe:

Network – 20% coinsurance
Non-Network – 20% coinsurance and any difference between allowed amount and retail cost

Major Restorative (Type C)
12-month waiting period. Waiting period will be waived for all enrollees with proof of 12 months of continuous dental coverage for major services immediately prior to the effective date of coverage in MCHCP’s Dental Plan.

Oral surgery & surgical extractions
Implants – once every 7 calendar years Endodontics / root canal therapy
Crowns – once every 7 calendar years
Dentures & bridges – once every 7 calendar years
Periodontics – surgical & non-surgical

Deductible applies, plus you owe:

Network – 50% coinsurance
Non-Network – 50% coinsurance and any difference between allowed amount and retail cost

Video Resources

MCHCP has created this video to help you in navigating the Delta Dental webiste.

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