|
Dental Plans
UT DENTAL SELECT Plan Booklet
Assurant Dental HMO Plan Booklet
Depending on where you live, you may have a choice between UT DENTAL SELECT, the self-funded dental plan, managed by Delta Dental, or Assurant Employee Benefits, a fully-insured dental HMO plan. Your Coverage Option Letter will tell you which plans are available to you.
The following chart shows which portion of the dental charges you are expected to pay and the service areas for each dental plan option:
Dental Plan Comparison Chart
| Dental Service |
UT DENTAL SELECT1 |
ASSURANT Pinnacle Plan |
| Service Area |
Available Worldwide |
Austin, Dallas/Ft. Worth, El Paso Galveston, Houston, San Antonio |
| Maximum Annual Benefit |
$1,250 |
None |
| Annual Deductible |
$25 per Person2 |
None |
| Oral Exam, X-rays, Cleaning |
$0 |
$0-5 |
| Fluoride Treatment |
$0, up to age 19 |
$0-5, up to age 18 |
| Sealants |
$0, up to age 14 |
$7, per tooth |
| Space Maintainers |
$0, up to age 14 |
$60-75 |
| Fillings |
20% |
$8-60 |
| Extractions |
20% |
$9-80 |
| Root Canals |
20% |
$95-175 |
| Periodontics3 |
20% |
$0-200 |
| Crowns, Jackets and Cast Restorations |
50% |
$235 (lab fees may also apply) |
| Bridges and Dentures |
50% |
$295-350 (lab fees may also apply) |
| Orthodontics |
50%, $1,250 Lifetime benefit per person |
25% discount of Dentist Retail Fee, no lifetime maximum |
| Out-of-Network Benefits |
Yes |
Limited to Emergencies |
1Reimbursement is based on a percentage of the allowable amount
2Excludes Oral exams, x-rays, cleanings, fluoride treatments, sealants, space maintainers
and specialist consultations
3Scaling, root planing and treatment of gum disease
UT DENTAL SELECT Highlights:
- You may see Network or Out-of-Network dentists
- DeltaPreferred Option dentists charge reduced contract fees
- No pre-approval needed to change dentists
- No referral needed to see a specialist
- 130,000 dental locations nationwide
- Delta Dental pays network dentists directly
Understanding Delta Dental's Unique Dentist Networks
DeltaPremier
- No advance billing
- No claim forms
- Dentist fees limited to DeltaPremier "allowance"
- No balance billing
- Out-of-pocket costs limited by Delta Dental's calculation of DeltaPremier "allowance"
- Credentialed dentist network
- Protection under Delta Dental's unique participating dentist agreements offering:
- quality assurance/consultant review
- cost management systems
- benefit of all Delta Dental policies and procedures
- Access to one of the largest dental PPO networks in U.S.
- 138,000 DeltaPremier Dental offices nationwide
DeltaPreferred Option (DPO)
UT DENTAL SELECT subscribers who choose a dentist from the smaller DPO network gain all the advantages of the larger DeltaPremier network plus:
- Out-of-pocket costs lower due to lower DPO "allowance"
- Discounted fee agreements average 30-35% off of submitted charges
- 64,000 DeltaPreferred Option (DPO) Dental Offices
Delta Dental Savings
Procedure: Two surface amalgam filling
| Sample Claim |
DPO Dentist |
DeltaPremier Dentist |
Non-Participating Dentist |
| Billed Charge |
$125 |
$125 |
$125 |
| Allowable |
$76 |
$101 |
$101 |
| Savings |
$49 |
$24 |
$24 |
| 80% Benefit Payment |
$61 |
$81 |
$81 |
| Patient Out of Pocket |
$15 |
$20 |
$44 |
Procedure: Porcelain Crown
| Sample Claim |
DPO Dentist |
DeltaPremier Dentist |
Non-Participating Dentist |
| Billed Charge |
$800 |
$800 |
$800 |
| Allowable |
$533 |
$710 |
$710 |
| Savings |
$267 |
$90 |
$0 |
| 50% Benefit Payment |
$267 |
$355 |
$355 |
| Patient Out of Pocket |
$266 |
$355 |
$445 |
*Billed charges are for illustration purposes only
Assurant DMO Highlights:
- No claim forms
- No deductibles
- No maximum annual benefit
- No maximum lifetime benefit for orthodontics
- Work in progress not covered
- Primary Family Dentist required for each family member
- No exclusions for pre-existing conditions
- No balance billing
- No referrals needed for Network specialists
You may read additional information about plan features and exclusions in the Dental Plan certificates available in the UT DENTAL SELECT Plan Booklet or the Assurant Dental HMO Plan Booklet. Your Campus Benefits office has a limited supply available for those without internet access.
Contact Information
|
UT Dental Select (Delta Dental)
www.deltadentalins.com/universityoftexas
(800) 893-3582 or
(800) 521-2651
6:15 AM - 6:30 PM CST
|
Assurant Dental DMO
www.assurantemployeebenefits.com
(800) 443-2995
7:00 AM - 5:30 PM CST |
