Owl Labs Understanding Your Ortho Benefits Flyer

UNDERSTANDING YOUR ORTHODONTIC BENEFITS Coverage Your dental plan provides the following coverage for orthodontic services: • 50% of your orthodontic costs. • Your coverage is based on the maximum allowable fee for orthodontic services. • Coverage is subject to a lifetime maximum of $1,500 per member. • All dependents are eligible for coverage up to the age of 19. • A maximum of 24 months of active treatment. Paying for orthodontic care In most cases, Delta Dental issues reimbursements for orthodontic care in automatic monthly payments not to exceed 12 installments. The first payment is based on the date of banding/placement of appliances. Additional payments will be issued automatically on a monthly basis assuming you are still eligible for orthodontic benefits. If you begin orthodontic treatment after your effective date of coverage and you receive care from a network dentist, Delta Dental will reimburse your dentist directly and send you and your dentist an Explanation of Benefits (EOB). The EOB will detail any payments made to the dentist. It is up to you and your dentist to develop a payment plan for the balance minus any Delta Dental adjustments. If you’ve already started your orthodontic treatment We provide pro-rated orthodontic benefits for members who are in active treatment and banded within 24 months of DDMA effective date. Coverage will be based on the maximum allowable fee, determined by the lower of the dentists submitted fee or contracted fee, and the time remaining in your treatment plan once your coverage with Delta Dental begins. To determine your coverage, we exclude the banding allowance, which we estimate to be 30% of total cost of treatment. Since that cost was incurred before your coverage began with Delta Dental, it is not covered. We process your benefit on the remaining 70% of the maximum allowable fee. Payment will vary based on banding date and effective date with Delta Dental. If banded less than 5 months from DDMA effective date, benefit is issued in automatic monthly payments. If banded more than 5 months from effective date with DDMA, benefit is issued in one lump payment. All payments are issued provided patient is in active treatment and covered by Delta Dental. Termination of Coverage In the event your coverage terminates before you complete your orthodontic treatment the automatic monthly payments will cease. Delta Dental of Massachusetts, 465 Medford Street, Boston, MA 02129 • www.deltadentalma.com An Independent Licensee of the Delta Dental Plans Association. ®Registered Marks of the Delta Dental Plans Association. ©2017 DSM. Delta Dental of Massachusetts SP1276 (10.17)