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SHOP 2017

2017 Small Business Health Options Program (SHOP)

Delta Dental of Kansas, Inc.is a Stand Alone Dental Plan, which offers the following Exchange-Certified plans for employees and/or their families.

 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 PPO -
Basic Family + Pediatric Oral Essential Health
  Benefit
     

Delta Dental PPO -
Preferred Family + Pediatric Oral Essential 
  Health Benefit
    

 Annual Benefit Maximum:                      

 per adult 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 below. 

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. 

 

Is your dentist in-network? 

You are free to visit any dentist of your choosing; however, there may be a difference in payment if the dentist is not a Delta Dental PPO dentist. Search for your dentist within the
Delta Dental PPO network.


Brokers & Group Administrators - Please contact a Delta Dental Sales & Marketing representative at 800.264.9462 for more information.

 

Click here to view Delta Dental of Kansas' Transparency in Coverage page.

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The following applies to the plans listed above:
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.

 DD6-011 (04/28/2016)