Dental Plan
through Delta Dental

Limitations and Exclusions | FAQs | Enrollment Guidelines | Dental Video

About the Plan

1. Available Services
2. How to Use the Dental Plan
   1. Coverage A
   2. Coverage B
   3. Coverage C
   4. Coverage D
3. Claim Predetermination
4. Claim Filing Deadline

Available Services
The two Delta Dental plan options available through MCHCP are Basic Option and High Option. The Basic Option offers coverage for preventive and diagnostic (A), basic and restorative (B) and major services (C). The High Option offers additional coverage for orthodontic (D) services. When your employer chooses dental coverage, only one of the two options will be offered.

How to Use the Dental Plan
After you are enrolled, Delta Dental will issue an ID card which you provide your dentist at the time of service. If you lose your ID card, you can contact Delta Dental for a replacement or download one.

The Delta Dental plan has a nationwide network of participating dentists that includes over 95% of dentists in Missouri. You may choose any dentist for treatment and use a network or non-network dentist.

Delta Dental network dentists are reimbursed based on what Delta Dental determines to be the usual, customary and reasonable (UCR) fee for services. Participating dentists accept the UCR amount as payment in full. When you use a Delta Dental network dentist, the dentist will file your claim for you and will not bill you for any amount that exceeds the UCR amount. You are responsible for any applicable deductible, coinsurance amount or amount over your annual maximum (per person). You are also responsible for any charges for procedures not covered by the dental plan.

You can visit Delta Dental to determine if your dentist is in the network or to find a participating dentist near you. If you use a non-participating dentist, you need to file the claim for your benefits, and Delta Dental will reimburse you for covered expenses. Keep in mind that the dentist may ask for full payment at the time of service, and the dentist may bill you for expenses above the amount Delta Dental reimburses.

If you see a non-participating dentist in Missouri, Delta Dental will pay you directly based on the dentist’s fee or the prevailing fee, whichever is less. If you go to an out-of-state non-participating dentist, Delta Dental will pay you on the same basis as the local Delta Dental plan reimburses its non-participating dentists.

Your dental benefits are provided according to a calendar year benefit period. An annual individual deductible of $50 must be met before your dental plan reimburses you for services. The annual $50 deductible can be met under B, C or D services or a combination of B, C and D services. There is no deductible for A services. Coverage is limited to a $1,000 maximum per person per calendar year.

Coverage A: Diagnostic & Preventive - paid at 100% with no deductible.

• Routine periodic examinations - twice per benefit period.
• Bitewing and periapical radiographs (x-rays) as required.
• Full-mouth radiographs (x-rays) - once in any 36 consecutive months.
• Dental prophylaxis (cleaning, scaling and polishing including periodontal maintenance) - twice per benefit period.
• Topical fluoride application for patients up to age 19 - once per benefit period.
• Emergency palliative treatment (minor procedures to temporarily reduce or eliminate pain) - as needed.
• Space maintainers that replace prematurely lost teeth of eligible dependent children up to age 16 - once in five years.
• Sealants: For dependent children under age 19, limited to caries-free first and second permanent molars - once in five years.

Coverage B: Basic & Restorative - paid at 80% after $50 annual deductible is met.

• Restorative services using amalgam, synthetic porcelain and plastic filling material.
• Periodontics: Treatment for diseases of the gums and bones supporting the teeth.
• Endodontics: Root canal filling and pulpal therapy.
• Simple and surgical extractions not covered by MCHCP’s plans.
• Oral surgery not covered by MCHCP’s medical plans.
• Denture repairs and relines.
• General anesthesia: When administered by a dentist properly licensed to administer general anesthesia for a covered surgical procedure.

Coverage C: Major Services - paid at 50% after $50 annual deductible is met.

• Prosthodontics: Bridges and dentures.
• Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes.

Coverage D (For High Option Only): Orthodontic Services - Services are covered at 50% after $50 annual individual deductible is met. There is a separate orthodontic lifetime maximum of $1,000 per dependent child under age 19.

Orthodontic care: Treatment for correction of malposed teeth to establish proper occlusion through movement of teeth or their maintenance in position. Applies to dependent children under age 19.

Claim Predetermination
If the care you need costs less than $200 or is emergency care, have your dentist proceed with treatment. If the care you need is likely to cost $200 or more and is not emergency care, your dentist could submit a treatment plan to Delta Dental of Missouri and receive a pre-determination of benefits before you proceed with treatment. This pre-determination of benefits will provide you with an estimate of costs and will enable you to know in advance of treatment how much of the cost will be reimbursed by Delta Dental and how much you will be responsible for paying (your out-of-pocket costs).

Claim Filing Deadline
Your claims must be filed by the end of the calendar year following the year in which services were rendered. Delta Dental of Missouri is not obligated to pay claims submitted after this period. If a claim is denied due to a participating dentist’s failure to make timely submission, you will not be liable to such dentist for the amount which would have been payable by Delta Dental, provided you advised the dentist of your eligibility for benefits at the time of treatment.

Claim forms can be obtained from MCHCP or
downloaded from Delta Dental.