HMO Dental Insurance for Individuals

1. This benefit information is only a summary and not intended or designed to replace or serve as the plan policy. Limitations may apply for some benefits; some services may be excluded from the plan.
2. You may view the DeltaCare USA Access Plan, as required by the Health Benefit Plan Network Access and Adequacy Act, online at deltadentalins.com. You may also contact us by calling 800-422-4234 to request a copy. 
3. In Florida and Texas, the copayment is 75% of contract orthodontist's filed fees.

DeltaCare USA plans are underwritten in these states by these entities: CA — Delta Dental of California; DC (Policy I-P-DC-dc-24) and FL — Delta Dental Insurance Company; MD and TX — Alpha Dental Programs, Inc.; UT — Alpha Dental of Utah, Inc.; NY — Delta Dental of New York, Inc.; NV — Alpha Dental of Nevada, Inc.; PA — Delta Dental of Pennsylvania. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products.

Delta Dental PPO plans are underwritten by Delta Dental Insurance Company in AL, DC (Policy IENT-P-CORE-DC-R24), FL, GA, LA, MS, MT, NV and UT and by not-for-profit dental service companies in these states: CA – Delta Dental of California; PA, MD – Delta Dental of Pennsylvania; NY – Delta Dental of New York, Inc.; DE – Delta Dental of Delaware, Inc.; WV – Delta Dental of West Virginia, Inc. In Texas, Delta Dental Insurance Company provides a dental provider organization (DPO) plan.

Please see your plan booklet or Policy for a complete description of plan benefits, limitations and exclusions.

In Florida, Delta Dental Insurance Company provides DeltaCare USA Plan benefits as a Prepaid Limited Health Service Organization as described in Chapter 636 of the Florida Statutes.

Maryland law requires we make the following statement:

Our compensation to physicians who offer health care services to our insured members or enrollees may be based on a variety of payment mechanisms such as fee-for-service payments, salary or citation. Bonuses may be used with these various types of payment methods.

Please note that the benefit payments made by Alpha Dental to dentists, other dental care providers or enrollees are based on capitation payment mechanisms and do not include salary or bonuses.

If you desire additional information about our methods of paying physicians or if you want to know which methods apply to your physician, call Customer Service at 800-422-4234 or write to DeltaCare USA, Attn: Customer Service, PO Box 1803, Alpharetta, GA 30023.

Provided by Alpha Dental Programs, Inc., 1701 Shoal Creek, Suite 240, Highland Village, TX 75077. Administered by Delta Dental Insurance Company, 1130 Sanctuary Parkway, Suite 600, Alpharetta, GA 30009. 

NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN. The group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of Coverage booklet will be sent to you upon enrollment.

$64.87 out of every $100 in premiums for DeltaCare USA were used to pay for health care claims during 2023. $35.13 are used to pay for administration.

90-I-A-2306-003