The calendar year maximum is the total amount the Fund pays in benefits in a calendar year. Once you reach the calendar year maximum, you pay the full cost of covered services.

Coinsurance is the percentage of the cost of the service. The amount of coinsurance depends on the type of service you are getting. When you pay coinsurance, you split the cost with the Fund. You pay a percentage of the cost while the Fund pays the rest.

The deductible is a fixed dollar amount. You pay the cost of a service out of your own pocket until you reach the deductible. After reaching the deductible, you pay coinsurance.

The lifetime maximum is a separate $2,500 orthodontic lifetime maximum that is not included in the $1,800 Calendar Year Maximum for dental benefits.

Out-of-network providers are providers that are not part of a network, such as Delta Dental’s PPO network, and have not signed a contract with Delta Dental. Out-of-network providers may charge more for services. You may owe certain out-of-pocket cost, such as a copayment, coinsurance, and/or deductible.

Balance Billing occurs when the dentist fees for services exceeds the plans “negotiated rate,” and the dentist bills the patient for the difference. Balance billing is allowed if the dentist provider is out-of-network. Providers who are in-network cannot balance bill the patient.

Example: Dental Plan covers 100% of preventive care, such as annual or semiannual visits for cleanings, sealants, and x-rays. Suppose the customary fee of a procedure in the preventive care category is $100 and the insurance plan approves $80. An in-network dentist cannot bill the patient the difference of $20, because of the negotiated rate between Delta and the provider. An out-of-network dentist can “balance bill” the patient for their full fee and collect the $20 difference.

In-network providers (those in the Delta Dental PPO and Premiere networks) charge a “negotiated rate.” This means they charge less for Fund members. You then pay a percentage of this negotiated, or less expensive, rate.