Exchange Certified Plans
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Exchange Certified Plans

Child-Only Coverage

These plans only provide coverage for enrollees age 18 and under.

Plan Options:                   

Choose between Basic or Preferred

  Delta Dental Individual and Family - 

Basic 
+ Pediatric Oral Essential Health Benefit

Delta Dental Individual
and Family -

Preferred 
+ Pediatric Oral Essential Health Benefit

Maximum Out-of-Pocket:                                       

per calendar year, for In-Network covered services only. This applies to
children age 18 and under.

  1 Child:     $350

 2+ children:      $700

1 Child:     $350

2+ Children:     $700

Deductible:

per calendar year               

 $70/person
($210/family)
$40/person
($120/family)

Your Dental Provider (Network) Options:            

Delta Dental PPO is In-Network  

Is your dentist in-network? Search for your dentist above. 

In-Network  PPO

     Out-of-      
Network
(non-PPO)

In-Network  PPO

     Out-of-      
 Network
(non-PPO)
 

 Service Type:  Percentage of what Delta Dental pays after deductible has been met.  Percentage of what Delta Dental pays after deductible has been met. 
Diagnostic and Preventive

Check-ups and cleanings
(once every 6 months)

X-rays, topical fluoride, sealants

100%

 80%



100%


 80%

Basic Services

Oral surgery, fillings, anesthesia, root canals, periodontal services

60%

 50%

80%

 60%

Major Services

Crowns, dentures, dental-related hospital services

50%

 40%

50%

 40%

Orthodontics

Braces for eligible children with documented medical necessity.

50%

 50%

 50%

 50%

 *This is a summary of benefits only and does not bind Delta Dental of Kansas to any coverage.     

 

 

 

Adult Coverage

These plans provide coverage for all adults age 19 and above, and include the pediatric coverage outlined above.

Your Family Plan Options:                   

Choose between Basic or Preferred
(both include the Child/Pediatric coverage described above)

  Delta Dental Individual and Family -  

Basic 
+ Pediatric Oral Essential Health Benefit

Delta Dental Individual
and Family - 

Preferred 
+ Pediatric Oral Essential Health Benefit

Annual Benefit Maximum:         

per enrollee, per calendar year

  $1,000

 $1,000

Deductible:

per calendar year               

 $70/person
($210/family)
$40/person
($120/family)

Your Dental Provider (Network) Options:            

Delta Dental PPO is In-Network 

Is your dentist in-network? Search
for your dentist above. 

In-Network
PPO

Out-of-Network
(non-PPO)

In-Network
PPO

     Out-of-      
 Network
(non-PPO) 

Service Type:Percentage of what Delta Dental pays after deductible has been met.Percentage of what Delta Dental pays after deductible has been met. 
Diagnostic and Preventive

Check-ups and cleanings (once every 6 months)
X-rays

100%

 80%



100%


 80%

Basic Services 
Emergency exam, oral surgery, fillings,
root canals, periodontal services

60%

 50%

80%

 60%

Major Services 
Crowns, bridges, partial and complete dentures

50%

 40%

50%

 40%

Orthodontics
Braces

Not Covered

 Not Covered

 Not Covered

 Not Covered

 *This is a summary of benefits only and does not bind Delta Dental of Kansas to any coverage.     

 


 

 


Exclusions and Limitations: Following is a list of common non-covered services. For a complete list of exclusions and limitations, refer to your contract. Services which are available from any Federal or State government agency, or similar entity; services for injuries compensable under an automobile policy or worker’s compensation or similar employer coverage; cosmetic services (unless stated otherwise); services started prior to coverage; services that are not completed; administrative fees such as missed appointments; temporary services and procedures; duplicate dentures; prescription drugs, premedications and relative analgesia, including hospital, healthcare facility or medical emergency room charges; laboratory charges; anesthesia for restorative dentistry; preventive control programs; injuries or disease intentionally self inflicted or occurring during or as a result of participation in riots or civil disobedience of any form, acts of war, or criminal activity; appliances or restorations to restore occlusion, splinting, equilibration, or replace tooth structure lost by attrition; restorations in conjunction with overdenture; inlays and onlays; non-medically necessary orthodontic services; services provided outside of the United States or Canada; dental implants; services related to TMJ; and services, supplies or treatments not specifically listed as covered in the member’s contract. Limitations: Services are limited to the least costly professionally accepted treatment to achieve reasonable functionality; costs of the procedures necessary to prevent or eliminate oral disease and for appliances or restorations to replace missing teeth as allowed by the plan; frequency and combined service limitations related to restorations, individual crowns, prosthetic appliances, and periodontic procedures as identified within the contract; and other frequency, age or contractual limitations as specified.

DD6-013(04/30/2014)