There is no increase in the monthly premium for the UT SELECT Dental or Assurant DMO plans for the 2008-2009 plan year.
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 DMO, a fully insured dental HMO plan administered by Assurant Employee Benefits. “Your UT Benefits Enrollment Options” letter/email 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 SELECT Dental1 |
ASSURANT Heritage Plus Plan |
| Service Area |
Available Nationwide |
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 14 |
$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 Fee, no lifetime maximum |
| Out-of-Network Benefits |
Yes |
Limited to Emergencies |
1The difference between BCBS Allowed and Billed Charges may be paid if that amount is in available COB Savings.
2A Provider who does not participate with Medicare may not bill more than the Medicare Limiting Charge (115% of MC Allowed).
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.
- 186,000 dental locations nationwide
- Delta Dental pays Network dentists directly.
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.
- 186,000 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 contracted "allowance"
- Discounted fee agreements average 30-35% off of submitted charges
- 97,000 DPO Dental offices
Delta Dental Savings
Procedure: Two surface amalgam filling
| Sample Claim |
DPO Dentist |
Delta Premier Dentist |
Non-Participating Dentist |
| Billed Charges |
$125 |
$125 |
$125 |
| Allowable |
$76 |
$101 |
$101 |
| Savings |
$49 |
$24 |
$0 |
| 80% Benefit Payment |
$61 |
$81 |
$81 |
| Patient Out of Pocket |
$15 |
$20 |
$44 |
Procedure: Porcelain Crown
| Sample Claim |
DPO Dentist |
Delta Premier Dentist |
Non-Participating Dentist |
| Billed Charges |
$901 |
$901 |
$901 |
| Allowable |
$602 |
$800 |
$800 |
| Savings |
$298 |
$101 |
$0 |
| 50% Benefit Payment |
$301 |
$400 |
$400 |
| Patient Out of Pocket |
$301 |
$400 |
$501 |
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) |
$95 |
| 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 enrolled member of your family. Each enrolled family member may choose a different Plan Dentist.
You have two options for locating Plan Dentists:
- Search online at www.assurantemployeebenefits.com/UT. Under “Find a Dentist”, select “Heritage Series”.
- Contact customer service at 800-443-2995 for assistance with locating or 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 6-8 weeks 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 SB 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) online at www.assurantemployeebenefits.com under “Find a Dentist”, select “Heritage Series”. When making an appointment, please confirm 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 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 online at www.assurantemployeebenefits.com/ut under “Find a Dentist”, select “Heritage Series”.
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, which can be obtained at www.assurantemployeebenefits.com/ut. 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 UT SELECT Dental Benefits Guide or the Assurant Dental HMO Benefits Guide.
