® DeltaCare - A Managed Care Dental Plan Administered by Delta Dental of Washington Introduction Welcome to your DeltaCare Plan, administered by Delta Dental of Washington, a founding member of the nationwide Delta Dental Plans Association. Our mission is to support your overall health by providing excellent dental benefits and the advantages of access to care within the largest network of Dentists in Washington and nationwide. Supporting healthy smiles has been our focus for over 60 years. Your DeltaCare Plan is a resource to make it easy for you to care for your smile. This benefit booklet summarizes your coverage and describes how your benefits may be used. Understanding your benefits is the first step to getting the most from your dental plan. Review this booklet before you visit your Dentist and keep it as a reference for later on. You deserve a healthy smile. We’re happy to help you protect it. Terms Used in This Booklet Annual open enrollment: A period of time defined by HCA when a Subscriber may change to another health plan offered by the PEBB Program and make certain other account changes for an effective date beginning January 1 of the following year. Appeal: An appeal is a written or oral request from an enrollee or, if authorized by the enrollee, the enrollee's representative to change a previous decision made by Delta Dental of Washington concerning: a) access to dental care benefits, including an adverse determination made pursuant to utilization review; b) claims handling, payment, or reimbursement for dental care and services; c) matters pertaining to the contractual relationship between an enrollee and Delta Dental of Washington or d) other matters as specifically required by state law or regulation. For an appeal related to PEBB eligibility or enrollment, see “Appeal rights” in the “Eligibility and Enrollment” section for more information. Continuation coverage: The temporary continuation of PEBB benefits available to enrollees under the Consolidated Omnibus Budget Reconciliation Act (COBRA), the Uniformed Services Employment and Reemployment Rights Act (USERRA), or PEBB policies. Copayment: The dollar amount enrollees pay when receiving specific services. Dental Emergency: The emergent and acute onset of a symptom or symptoms, including severe pain that would lead a prudent layperson acting reasonably to believe that a dental condition exists that requires immediate dental attention. Dental Necessity: A service is “dentally necessary” if it is recommended by the treating provider and if all of the following conditions are met. Dependent: Eligible dependent as described in the dependent eligibility section of this certificate who is covered under the subscriber. Employing agency: A division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by HCA statute. Enrollee: The subscriber or dependent enrolled in this plan. 2024-01-03100-BB 1 DCL 20240101