Dental Plans

UT SELECT DENTAL Benefit guide
Assurant Dental HMO Benefit Guide

Dental Plan Options

Depending on where you live, you may have a choice between UT SELECT DENTAL , the self-funded dental plan administered 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. As of September 1st, there is approximately a 7% increase in the monthly premium for UT SELECT DENTAL and a 0% increase for the Assurant Dental DMO.

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 SELECT DENTAL 1	ASSURANT Heritage Plus 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, up to age 14
Sealants	$0, up to age 15	$10, per tooth
Space Maintainers	$0, up to age 14	$60-105
Fillings	20%	$10-110
Extractions	20%	$15-135
Root Canals	20%	$90-175
Periodontics3	20%	$27-140
Crowns, Jackets and Cast Restorations	50%	$275 (lab fees may also apply)
Bridges and Dentures	50%	$275-400 (lab fees may also apply)
Orthodontics	50%, $1,250 Lifetime benefit per person	25% discount off Network Dentist retail fees, 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 SELECT DENTAL Highlights:

• You may see Network or Out-of-Network dentists.
• Two Networks: DPO and Delta Premier
• Pre-approval is not required to change dentists.
• Referrals are not required to see a specialist.
• 165,000 dental locations nationwide
• Delta Dental pays Network dentists directly
• Two Additional Cleanings per year are covered for members with Periodontal Disease.

Understanding Delta Dental's Two Unique Dentist Networks

DeltaPremier

UT SELECT DENTAL subscribers who choose a Delta Premier dentist receive these benefits:

• 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
• the benefit of all Delta Dental policies and procedures
• Access to one of the largest dental networks in U.S.
• 165,000 DeltaPremier Dental offices nationwide

DPO (Dental Provider Organization)

UT SELECT DENTAL 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
• 90,000 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-DeltaPremier Dentist
Billed Charge	$901	$901	$901
Allowable	$602	$800	$800
Savings	$200	$101	$0
50% Benefit Payment	$301	$400	$400
Patient Out of Pocket	$301	$400	$501

*Billed charges are for illustration purposes only

Assurant Dental Maintenance Organization (DMO)

The DMO plan offered to you by Assurant Employee Benefits is called the Heritage Plus plan. The chart below provides examples of several copayment amounts for the Heritage Plus plan:

Copayment Examples

ADA Code	Procedure	Heritage Plus Plan Copayment
None	Office Visit	$0
0210	X-Ray	$0
0330	Panoramic X-Ray	$5
1110	Adult Cleaning	$0
1120	Child Cleaning	$0
2150	Amalgam Filling (2 Surface)	$15
2331	Resin Filling (2 Surface)	$40
2740*	Crown	$275
2962*	Labial Veneer	$290
3310	Root Canal (Anterior)	$165
7140	Extraction, erupted tooth or exposed root	$15
9972	External Bleaching (per arch)	$155

*Members are responsible for additional lab fees for these services

Selecting and Changing a Dentist

At the time of enrollment you will need to select a Plan Dentist for yourself and each eligible member of your family. Each eligible family member may choose a different Plan Dentist.

There are two options for locating Plan Dentists:

• Review the provider directory included in the enrollment booklet.
• Search online at www.assurantemployeebenefits.com/UT. Under “Find a Dentist”, select “Heritage Series”.

Contact customer service for assistance with changing your Plan Dentist.

The dental plan is simple to use when you follow these steps:

• Verify with your Plan Dentist that you are on their roster before making a dental appointment.
• Call early for routine dental care for the best availability of appointment times.
• Be familiar with your copayment schedule to determine your costs for dental services.
• Discuss concerns regarding proposed treatments with your Plan Dentist.

When you Need to See a Specialty Dentist

All Assurant enrollees are eligible for the Specialty Benefit (SB). The SB offers three benefit options when seeking treatment from a specialty dentist. With your Assurant Heritage Plus Plan, a referral is not necessary.

Option One:

When seeking treatment by an SB Plan Specialty Dentist including in-Network Endodontists, Periodontists and Oral Surgeons who accept the SP Copayment Schedule, here is how the benefit works:

• You pay a fixed copayment amount for services listed on the SB Copayment Schedule, which is much lower than the normal retail charge.
• You receive a 25% discount for procedures not listed on the SB Copayment Schedule (15% discount for Endodontist) off the normal retail charge. This includes a 25% discount on orthodontic and pedodontic services.
• To find an SB Specialty Dentist, please refer to the Provider Directory (indicated with an S) or online at www.assurantemployeebenefits.com under “ Find a Dentist”. When making an appointment, please confirm that your chosen Specialty Dentist participates in the SB.

If you do not see a Plan Specialty Dentist who participates in the SB, the following options are available to you. We recommend that you call Customer Service for assistance in determining your best option.

Option Two:

When seeking treatment from a Network Specialty Dentist who does not participate in the SB, you will receive a flat discount on all procedures.

• You will receive a 25% discount off the Specialty Dentist’s (excluding Endodontist’s) normal retail charge. You will receive a 15% discount off an Endodontist’s normal retail charge.
• To find a Plan Specialty Dentist, please refer to the Provider Directory or online at www.assurantemployeebenefits.com/ut under “Find a Dentist”.

Option Three:

When seeking treatment from an Out of Network Specialty Dentist, you can still receive a benefit under the plan. Plan benefits are provided for procedures listed in the Maximum Non-Plan Specialty Reimbursement list. A claim must be submitted to Assurant Employee Benefits. Here’s how it works:

• At the time of service you pay the Specialty Dentist’s normal retail charge for the services performed.
• If the procedure is listed on the SB Schedule, you will be reimbursed the amount shown in the Maximum Non-Plan Specialty Reimbursement list or the amount charged by the specialty dentist for the procedure, whichever is less. An annual $2,000 maximum applies.
• No benefits are available for services not listed on the SB Schedule.

You may read additional information about plan features and exclusions in the Dental Plan certificates available in the UT SELECT DENTAL Plan Guide or the Assurant Dental HMO Plan Guide. Your Campus Benefits office has a limited supply available for those without internet access.

Contact Information

UT SELECT DENTAL (Delta Dental)
www.deltadentalins.com/universityoftexas
(800) 893-3582 or
(800) 521-2651
6:15 AM - 6:30 PM CST