Dental Insurance Thomas College offers two dental plans from Northeast Delta Dental. You can go to any dentist that you want, but if you receive services from a participating dentist, you will not be billed for amounts over Delta's allowances.
Preventive Services
Basic Services
Major Services
Orthodontic Services
No Deductible
Low Plan- $50/$150 One time Deductible per Person/Family High Plan- $100/$300 One time Deductible per Person/Family
Low Plan- You pay 50% High Plan- You pay 50%
Low Plan- You pay 50% High Plan- You pay 50%
Low Plan- You pay 4 0% High Plan- You pay 20%
Covered in full
Low Plan- $1,000 per Member High Plan- $1,500 per Member Lifetime Maximum
Low Plan- $1,000 Calendar Year Maximum per Member High Plan- $2,000 Calendar Year Maximum per Member
Services include:
Services include:
Services include:
Services include:
Exams (2 per benefit period) Bitewing X-rays Cleanings ( 2 per benefit period) Sealants, age 15 and under (limitations apply) Fluoride, age 1 5 and under (limitations apply)
Crowns Crown repair Onlays Dental implants Partial & full dentures
Amalgam fillings Composite fillings Oral surgery Endodontic services (root canals) Periodontal services (gum disease) Routine extractions Space maintainers to age 15 Full mouth/panoramic x- rays once per 5 year period
Correction of malposed (crooked) teeth for adults and dependent children
Double-Up Max This dental plan includes a valuable feature that allows qualifying plan participants to carryover part of their unused annual maximum. A participant earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. In addition, a person earning dental rewards who submits a claim for services received through the dental network earns an extra reward, called the PPO Bonus. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan participant doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year. Benefit Threshold $ 500 Dental benefits paid for the year cannot exceed this amount Annual Carryover Amount $ 250 Max Builder amount is added to the following year’s maximum Annual PPO Bonus $ 100 Additional bonus earned if the participant sees a network provider Maximum Carryover $1,000 Max possible accumulation for Max Builder and PPO Bonus combined
Tier Employee Only Employee + Spouse Employee + Child(ren) Family
Per Pay Period- Low Plan $ 17.73 $ 33.23 $ 35.51 $ 58.57
Per Pay Period - High Plan $ 23.58 $ 44.18 $ 47.23 $ 77.49
This Guide is for illustrative purposes only and is not a legal contract, contract of employment or guarantee of coverage. Any benefits payable will be subject to the terms and conditions of the insurance policy issued by the insurance company and relevant plan document. 31
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