Dental

RESOURCES

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

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.
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.
194,400 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
116,000 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. If you do not select a Plan Dentist, one will be selected for you. Services must be provided by this selected dentist unless you contact Assurant to change your Plan Dentist selection.

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.