Department of Human Resources

Delta Dental of Arkansas

PO Box 15965
North Little Rock, AR 72231
Tel: 1-800-462-5410

www.deltadentalar.com


CONTENTS:        

Description
Eligibility
Enrollment
Deductibles & Co-Pays
Cost
Benefits
Claims
Questions/Contact Information
Forms


DESCRIPTION:

Delta Dental is the college's dental provider. To receive maximum coverage under the plan, employee must see in-network providers, under Delta Dental Premier or Delta Dental PPO Network. The in-network provider directory is available by clicking here (select Find A Dentist).


 

ELIGIBILITY:

All full-time employees are eligible for coverage. Spouses and legally dependent children up to age 26 may also be eligible.


 

ENROLLMENT:

New Hires:  All full-time employees are eligible to apply for coverage upon hire. If election is made upon hire, coverage becomes effective the first of the month following 30 days of employment.

Qualifying Family Status Changes:  Changes to coverage may be made within 30 days of a qualifying family status change.  Examples of a qualifying family status change are birth or adoption of a child, marriage, divorce and loss of other coverage.

Annual Open Enrollment:  Each fall there is an annual open enrollment period in which employees can add, cancel or change their enrollment.


 

DEDUCTIBLES & CO-PAYS:

The employee is responsible for a plan year deductible per insured for certain services. The calendar year deductible is $50 for individual; maximum family deductible is $150. There is an Annual Maximum Payment of $1000 per person per calendar year.

The plan pays 100% of Diagnostic and Preventative Services; 80% of Basic Restorative Services and 50% of Major Restorative Services if the provider is within the Delta Dental Premier or Delta Dental PPO Network. The benefit allowance for services of an out-of-network dentist will be reduced by 10% for eligible services as determined by Delta Dental after applying the applicable deductibles, co-payments and maximums. This means that out-of-pocket expense may be greater if an out-of-network dentist is used.

The plan offers a Child Orthodontic Rider for dependent children to age nineteen (19).


 

 

 

 

 

 

 

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COST:

Monthly Premiums as of January 1, 2014:

 

 
Total Premium Rate Effective 1/1/2014
Monthly Premium Amount Paid by NWACC
Monthly Premium Amount Paid by Employee
Employer Contribution Per Pay Period
Employee Deduction  Per Pay Period
Employee Only
$29.70
$29.70
$ 0.00
$14.85
$ 0.00
Employee/Spouse
$59.36
$29.70
$29.66
$14.85
$14.83
Employee/Child(ren)
$76.62
$29.70
$46.92
$14.85
$23.46
Employee/Family
$94.92
$29.70
$65.22
$14.85
$32.61

 

 


 

BENEFITS:

Coverage includes but is not limited to:

  • Routine periodic examinations
  • Prophylaxis cleaning
  • Bitewing and Periapical X-rays as required
  • Simple extractions
  • Oral surgery
  • Non-surgical and surgical periodontics
  • Crowns, inlays, onlays and veneers

 

 

 

 

 

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CLAIMS:

All claims must be filed within twelve (12) months after completion of treatment for which benefits are payable. Any claim filed after this period will be denied.

PARTICIPATING DENTISTS, will complete and submit claim forms for participants. If the participant visits a NON-PARTICIPATING DENTIST, participant may be required to complete a claim form or pay a service charge.

For services provided by a PARTICIPATING DENTIST, payment will be made to the PARTICIPATING DENTIST. For services provided by a NON-PARTICIPATING DENTIST, payment will be made to SUBSCRIBER. The SUBSCRIBER is responsible for all payments to a NON-PARTICIPATING DENTIST.


 

 

 

 

 

 

 

QUESTIONS/CONTACT INFORMATION:

For questions about the benefits offered through this plan, contact your Benefits Coordinator.

For questions about processing a claim form or problems in receiving reimbursement, contact Delta Dental of Arkansas at 1-800-462-5410 or write to: Delta Dental Plan of Arkansas, PO Box 15965, North Little Rock, AR 72231

Delta Dental web site is www.deltadentalar.com


 

 

 

 

 

FORMS:

Enrollment/Change Form
Claim Form

 

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