Find out if you qualify for continuous orthodontic coverage
when you switch to DeltaCare
®
USA.
Through a provision called orthodontic treatment in progress,
Delta Dental of California allows you to continue treatment
you started under your previous dental plan with your current
employer/organization. You have the convenience of visiting
the same orthodontist and enjoying the same coverage and
copayments as under your previous program. You pay the same
amount that you would have paid under your previous coverage,
as long as you remain eligible for coverage under the DeltaCare
USA plan.
If you started orthodontic treatment under your former dental
carrier, and if banding has taken place, you are eligible for continuous
coverage under the DeltaCare USA program and may continue to
visit the same orthodontist.
If banding has not occurred, you are not eligible for continuous
orthodontic coverage. In that case, orthodontic treatment
must be provided by a Delta Dental of California network
orthodontist in accordance with the copayments, limitations
and exclusions dened in your DeltaCare USA program. Please
review the enrollment materials that accompany this yer
for details.
To begin orthodontic treatment, you must select a Delta Dental
of California network orthodontist to receive your DeltaCare
USA orthodontic benets. Your copayments, limitations and
exclusions are determined by your DeltaCare USA program.
Please complete the form below and return it to Delta Dental
of Californiawithin 30 days of your employer/organization’s
original effective date or within 30 days of your eligibility for
benets, if you are a new employee. Delta Dental of Californiawill
coordinate as necessary with your existing orthodontist. Upon
enrollment under the DeltaCare USA plan, you will receive an
Evidence of Coverage (EOC) booklet. Please retain this yer and
keep it with your EOC.
This coverage is available only in California, District of Columbia,
Florida, Georgia, Maryland, Nevada, New York, Pennsylvania, Texas,
Utah and West Virginia.
DeltaCare USA is underwritten in these states by these entities:
AL — Alpha Dental of Alabama, Inc.; AZ — Alpha Dental of
Arizona, Inc.; CA — Delta Dental of California; CO, MI, OR, RI,
WA, WI — Dentegra Insurance Company; FL, GA, KS, TN, WV
and Washington, D.C. — Delta Dental Insurance Company; KY,
MD, MO, TX — Alpha Dental Programs, Inc.; NV — Alpha Dental
of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.; NM — Alpha
Dental of New Mexico, Inc.; NY — Delta Dental of New York;
PA — Delta Dental of Pennsylvania. Delta Dental Insurance
Company acts as the DeltaCare USA administrator in all these
states, except CA. These companies are nancially responsible
for their own products.
CONTINUOUS ORTHODONTIC COVERAGE FORM
If your previous orthodontic coverage was through a dental program and you
meet all of the above conditions, please provide the following information:*
Primary enrollee’s name: _____________________________
Primary enrollee’s phone number: ______________________
Primary enrollee’s social security #: _____________________
Name of employer/organization: _______________________
Patient’s name: ____________________________________
Previous dental carrier: ______________________________
Banding date of patient: _____________________________
Mail to:
Claims Department, M/S CL710
Delta Dental of California
12898 Towne Center Drive
Cerritos, CA 90703
Orthodontist’s name:
_______________________________________________
Orthodontist’s address:
_______________________________________________
_______________________________________________
_______________________________________________
Orthodontist’s phone number: ________________________
_______________________________________________
* This form must be sent to Delta Dental of California within
30 days of your employer/organization’s original effective
date with Delta Dental of California or within 30 days of
your eligibility for benets, if you are a new employee.
Welcome to the DeltaCare USA prepaid dental program,
administered by Delta Dental of California.
If you or an eligible member of your family has started
orthodontic treatment under a previous program sponsored by
an employer or organization, you may be able to continue that
coverage when you switch to DeltaCare USA.
How does continuous orthodontic coverage work?
How do I qualify for continuous orthodontic coverage?
How do I sign up for continuous orthodontic coverage?
What if I am about to begin orthodontic treatment?
