Delta Dental of South Dakota wants you to be an informed and satisfied consumer. Helping you understand your dental benefits is one way to ensure you get the most appropriate and cost-effective care.

What is a Dental Plan?
Dental plans differ from health plans. Most health plans are designed to cover services that are medically necessary to treat specific conditions or diseases. This allows you the flexibility to respond to your individual medical needs and avoid significant financial burdens.

Your dental plan serves a different purpose. Your employer offers a dental benefit plan to provide financial assistance to meet general dental care needs. The focus is on prevention. Most dental plans are structured to provide coverage that meets basic diagnostic and preventive dental needs. Depending on you and your family's oral health, your dental plan may not cover all your needs and should not be the sole determinant of the dental treatment you receive.

The best way to take full advantage of your dental plan is to understand its features. Our best advice is to: Read your dental benefits handbook for a complete description of your plan coverage or click on Subscriber Connection for your plan's coverage.

Delta Dental of South Dakota offers a variety of plans with different features. Your friends or neighbors may be covered by a Delta plan, but their employer may have chosen a different combination and extent of benefits than your employer.

Although nearly 95% of South Dakota dentists participate with Delta Dental, your dentist may not be a participating dentist. If your dentist is a participating dentist, he or she will submit your claim. If not, you may be responsible for paying your dentist and submitting your claim to Delta Dental of South Dakota.

If you are entitled to benefits from more than one dental plan (for example your spouse's plan), the amounts paid by the combined plans will not exceed 100 percent of your dental expenses. Benefits for dependents vary from plan to plan. Pay particular attention to special clauses and to language about dependents.

Benefit Periods
Most dental benefits are calculated within a "benefit period," which is typically for one year but not always a calendar year. Go to Subscriber Connection or read your handbook to find out when you might be approaching your deductible limits or program maximums.

Maximums
Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period. The patient is personally responsible for paying costs above the annual maximum.

Deductibles
Some dental plans have a specific dollar deductible. It works like your car insurance deductible. During a benefit period, you will have to personally pay a portion of your dental bill before your insurance carrier will contribute to your bill. Your handbook will describe how your deductible works. Plans do vary on this point. For instance, some dental plans will apply the deductible to preventive treatments, and others will not. To determine your deductible for this benefit period, check your benefits.

Coinsurance
Many insurance plans have a coinsurance policy. That means the insurance carrier might pay a predetermined percentage of the cost of your treatment, and you are responsible for paying the balance. The amount you pay is called coinsurance. It is paid even after a deductible is reached.

Coordination of Benefits
If you are covered under another dental plan, Delta Dental will coordinate your covered benefits as described in your dental benefits handbook. Among other things, Coordination of Benefits eliminates duplicate payments for the same dental or orthodontic services. Please see your handbook for details on the rules regarding which insurance plan would be considered primary and which would be considered secondary for payment purposes.

Predetermination of Benefits (Estimate of Benefits)
Another aspect of Delta Dental's quality assurance is cost management. It's a responsibility we have to you, our customer. To fulfill that responsibility, we're tracking and analyzing costs at every step of the process. Delta Dental's close relationship with our participating dentists goes a long way toward achieving cost-conscious coverage for you.

To assist you in managing your total costs, Delta Dental offers what is called "predetermination of benefits." Dentists may submit their treatment plan to Delta Dental for review and estimation of coverage before procedures are started. Delta Dental advises the patient and the dentist regarding the services that will be covered and your potential out-of-pocket costs. The actual payment for these pre-determined services depends on eligibility, any plan limitations, coordination of benefits and the remaining maximum at the time services are performed. A pre-determination plan is subject to change based on the dentist's participation status at the time of treatment and does not guarantee direct payment. Once issued, a predetermination plan is valid for 90 days. Of course, pre-determination is optional, but it is strongly recommended for dental services expected to exceed $500.

Limitations and Exclusions
Dental plans are designed to help with your dental expenses and may not always cover all your diagnosed dental or medical needs. The typical plan includes limitations and exclusions, meaning the plan doesn't cover every aspect of dental care. This can affect the type of procedures performed or the number of visits. These limitations and exclusions are carefully detailed in your dental benefits handbook and should be looked at carefully. Again, the handbook will help you develop realistic expectations of how your dental plan can work for you.