ONLINE BENEFITS DIRECTORY

Dental

 


www.deltadentalsc.com

Customer Care:  1-800-335-8266

Eligibility

You must enroll online (see page 8 in the Yellow Book for instructions) by the deadline provided by the . Your effective date is on the first day of the month following two (2) full calendar months of employment. If you enroll dependents you must prove eligibility. Dependent Eligibility forms are found on the Enrollment site https://jmsmith.bcenroll.net > Posted Forms.

 NOTE: If you do not enroll in Dental Benefits when first ‘eligible’, waiting periods for dental benefits apply

 

DENTAL COVERAGE  

 

ServiceCoverage
Annual Deductible $50 per person
Annual Maximum
Non-orthodontic care$1,500 (per calendar year)
Orthodontic care$1,500 (lifetime maximum)
PREVENTIVE SERVICES
Oral exams (2 exams per 12 months)Plan pays 100% of the allowable charges, you pay 0% Waiting Period for Benefits to begin: None
Cleanings (2 exams per 12 months)Waiting Period for Benefits to begin: None
Bitewing x-rays (2 every 12 months)
Full set of x-rays (every 36 months)
Space maintainers for dependent children under the age of 16
Fluoride treatments for dependent children under the age of 18 (2 each calendar year)
Sealants for dependent children under the age of 18 once per tooth in any 36 months
BASIC SERVICES
Fillings, other than gold Plan pays 80% of the allowable charges, you pay 20% (Subject to the deductible if not already met)
Extractions
PeriodonticsWaiting Period for benefits to begin: Late Entrants Only - The first 6 months of the covered person's coverage
Oral Surgery
Anesthesia
Laboratory tests
MAJOR SERVICES
Crowns,Dentures & BridgeworkPlan pays 50% of the allowable charges, you pay 50% (Subject to the deductible if not already met)
Repairs to crowns, bridges and denturesWaiting Period for benefits to begin: Late Entrants Only - The first 6 months of the covered person's coverage
Dental Implants
ORTHODONTIC SERVICES
Benefit is available for adults and childrenPlan pays 50% of the allowable charges, you pay 50%
Waiting Period for Benefits to begin: Late Entrants Only - The 1st 24 months of the covered person's coverage

Note:  This is a convenient brief summary.  Always check your booklet certificate. The contract is the official source of information.

DENTAL BENEFITS GUIDE


Delta Dental Guide

Continuing coverage after I stop working

You may continue coverage for you and your covered dependents at your own expense under COBRA.  You will be provided with information and costs upon leaving your employment with J M Smith Corporation.

Your dental benefits are administered by Delta Dental of Missouri (DDMO), a not-for-profit corporation.

You may visit the dentist of your choice and select any dentist on a treatment by treatment basis. It is important to remember your out-of-pocket costs may vary depending on your choice. You have three options.

1. PPO Participating Dentist (Delta Dental PPO Network). Delta Dental’s PPO network consists of dentists who have agreed to accept payment based on the lesser of usual fees or the applicable PPO Maximum Plan Allowance and to abide by Delta Dental policies. This network offers you cost control and claim filing benefits.

2. Non-PPO Participating Dentist (Delta Dental Premier Network). Delta Dental’s Premier network consists of dentists who have agreed to accept payment based on the lesser of filed fees or the applicable Premier Maximum Plan Allowance. This network also offers you cost control and claim filing benefits. However, your out-of-pocket expenses (deductibles and coinsurance amounts) may be higher with a Premier dentist, based upon your plan design.

3. Non-Participating Dentist. If you go to a non-participating dentist (not contracted with a Delta Dental plan), DDMO will make payment directly to you based on the lesser of the dentist’s billed charge or the applicable Maximum Plan Allowance. It will be your obligation to make full payment to the dentist and file your own claim. A Dental Claim Form is available at the bottom of this page.

Other resources

Pam Watson
Employee Health Plan Advocate
pwatson@jmsmith.com
864.542.9419 ext 5483 or
800.428.7281 ext 5483


Phone: 864-582-1216 ext. 1508

Online forms

Delta Claim Form
JM Smith Benefit Summary Basic Dental Plan
JM Smith Benefit Summary Premium Dental Plan

Online booklet


Delta Summary Plan Description