Smart Options for Protecting Smiles & Budgets
Delta Dental of Illinois Individual
and Family Insurance
Our dental benefit plans offer individuals, couples and families without
an employer-sponsored dental plan access to affordable care.
2
Individual Dental Plans
With Delta Dental of Illinois’ individual dental plans, members can protect their oral health and
their wallets. Our individual dental coverage gives consumers a choice of plans focused on
providing access to preventive care at aordable rates.
And because oral health care is so important to overall health, our individual coverage includes
Delta Dental of Illinois’ Enhanced Benefits Program*, which oers enhanced coverage for
individuals who have specific health conditions that can be positively aected by additional
oral health care – like pregnancy, diabetes, high-risk cardiac conditions and suppressed immune
systems.
We also oer an Individual Kids Basic plan, which meets the guidelines of the Aordable Care Act’s
(ACA) Pediatric Dental Essential Health Benefit (EHB). The Individual Kids Basic plan can be purchased
on a stand-alone basis, or with Delta Dental PPO
SM
– Gold and Silver individual plans.*
Delta Dental of Illinois Individual Plans Oer:
• Flexible coverage options.
• Rich coverage for preventive services like exams, cleanings, X-rays, sealants and fluoride
treatments.
• Coverage for major services like gum disease treatment, root canals, dentures and crowns.
• Freedom to use any dentist (the most out-of-pocket savings will be realized with a Delta Dental
PPO dentist).
• Rates as low as $15 per month for an individual with monthly payment options.
• Outstanding customer service provided by Illinois’ most experienced dental carrier.
• Ability to purchase the Individual Kids Basic plan, an ACA compliant pediatric dental plan, on a
stand-alone basis for children under age 19. Members under age 19 can use the benefits of both
plans but can only receive benefits from the Individual Kids Basic plan with Delta Dental PPO
dentists.
Network Savings
Delta Dental of Illinois’ individual plans are based on the Delta Dental PPO network. Delta Dental
Premier
®
and non-network dentists can bill the enrollee for charges above the allowed Delta Dental
PPO amount. However, Delta Dental Premier dentists cannot bill for charges above the allowed
Delta Dental Premier amount. The Individual Kids Basic plan, an ACA compliant pediatric dental
plan, uses an Exclusive Provider Feature where benefits are paid only when a member sees a Delta
Dental PPO dentist.
• Delta Dental PPO network: Lowest out-of-pocket costs.
• Delta Dental Premier network: Higher out-of-pocket costs than PPO, but may be lower than
non-network costs. (With the Individual Kids Basic plan, there are no benefits with dentists who
are not in the Delta Dental PPO network.)
• Non-network: Highest out-of-pocket costs. (With the Individual Kids Basic plan, there are no
benefits with dentists who are not in the Delta Dental PPO network.)
* The Enhanced Benefits Program is included with Delta Dental PPO – Gold and Silver plans and the Individual Kids Basic plan.
The Delta Dental PPO – Bronze plan oers additional general cleanings and fluoride for at-risk individuals.
** Single rates are not available for Delta Dental PPO – Gold and Silver plans with the Individual Kids Basic plan; there must be one
adult and one or more dependents enrolled in these plans. Single rates are available for all other plans
Delta Dental of Illinois does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual
orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
3
Delta Dental PPO
SM
– Gold Plan with the Individual Kids Basic Plan
Delta Dental PPO – Gold Plan
The Gold plan is based on the Delta Dental PPO network. Delta Dental PPO
dentists cannot bill over the PPO allowed amount. Delta Dental Premier and
non-network dentists can bill for charges above the allowed Delta Dental PPO
amount. However, Delta Dental Premier dentists cannot bill for charges above
the allowed Delta Dental Premier amount.
Individual Kids Basic Plan
(Children under age 19 only)
The Individual Kids Basic plan uses an Exclusive Provider Feature where
benefits are paid only when a member uses a Delta Dental PPO dentist. Delta
Dental PPO dentists cannot bill members for charges over the PPO allowed
amount. There are no benefits when a member uses a non-Delta Dental PPO
network dentist. Members under age 19 can use the benefits of both the
Gold and Individual Kids Basic plans, but can only receive benefits from the
Individual Kids Basic plan with Delta Dental PPO dentists.
Deductible
(benefit year; per person, applies to all services)
$50
Deductible
(benefit year; per person, applies to basic and major
services only)
$120
Out-of-Pocket Limit N/A Out-of-Pocket Limit
$350 per
individual
child
Annual Maximum (benefit year) $1,500
Family Out-of-Pocket Limit (for children under age 19)
$700
Covered Dental Services
Preventive Services
• Exams (limited to 2 per person in a benefit year)
• Cleanings (limited to 2 per person in a benefit
year)
• Bitewing X-rays (limited to 1 set per person in a
benefit year)
• X-rays (full mouth/panoramic – limited to 1 per
person in 36 months)
• Fluoride Treatments (limited to 1 per person in a
benefit year, under age 16)
• Space Maintainers (under age 14)
• Sealants (under age 16)
100%
Preventive Services
• Exams (limited to 2 per person in a benefit year)
• Cleanings (limited to 2 per person in a benefit
year)
• Bitewing X-rays (limited to 2 per person in a
benefit year)
• X-rays (full mouth/panoramic – limited to 1 per
person in 36 months)
• Fluoride Treatments (limited to 1 per person in a
benefit year, under age 19)
• Space Maintainers (under age 19)
• Sealants (under age 19)
100%
in-
network/
0%
out-of-
network
Basic Services (6 month waiting period**)
• Fillings/Amalgams
• Simple Extractions
50%
Basic Services
• Fillings/Amalgams
• Simple Extractions
• Gum Disease Treatment
• Root Canals
• Surgical Extractions
50%
in-
network/
0%
out-of-
network
Major Services (12 month waiting period**)
• Gum Disease Treatment
• Root Canals
• Surgical Extractions
• Denture Relines and Rebases, Adjustments
• Repairs to Crowns, Dentures and Bridges
• Crowns
• Complete and Partial Dentures
• Fixed Bridgework
50%
Major Services
• Denture Relines and Rebases, Adjustments
• Repairs to Crowns, Dentures and Bridges
• Crowns
• Complete and Partial Dentures
• Fixed Bridgework
50%
in-
network/
0%
out-of-
network
Enhanced Benefits Program
Oers additional coverage for individuals who have
specific health conditions (including pregnancy,
diabetes, high-risk cardiac conditions and
suppressed immune systems) that can be positively
aected by additional oral health care.
Included
Enhanced Benefits Program
Oers additional coverage for individuals who have
specific health conditions (including pregnancy,
diabetes, high-risk cardiac conditions and
suppressed immune systems) that can be positively
aected by additional oral health care.
Included
Orthodontia
Not
included
Orthodontia (medically necessary orthodontia only)
The ACA requires coverage for medically necessary
orthodontia only. Predeterminations will be
necessary to determine if there is any coverage for
orthodontia under the Individual Kids Basic plan.
50%
in-
network/
0%
out-of-
network
Visit deltadentalil.com/healthalliance for monthly premiums and to enroll members or call 800-323-1743.
** Single rates are not available for Delta Dental PPO – Gold and Silver plans with Individual Kids Basic plan; there must be one adult and one or more dependents
enrolled in these plans. Single rates are available for all other plans
** The waiting period is waived if the member was covered under a Delta Dental of Illinois group-sponsored policy within 60 days of the start of coverage under
this policy, and had at least 12 months of continuous coverage under that plan. Waiting periods must be satisfied if there has been a lapse in coverage or for new
members who are added to this policy.
There is a 24-month waiting period to re-enroll if the member drops coverage. Subsequent rate changes will be reviewed prior to the renewal date subject to
a 60-day notification. Applications must be received by the 20th of the month to be eective the 1st of the following month. Applications received after the
20th will be eective the 1st of the month after the next month.
4
Delta Dental PPO
SM
– Silver Plan with the Individual Kids Basic Plan
Delta Dental PPO – Silver Plan
The Silver plan is based on the Delta Dental PPO network. Delta Dental PPO
dentists cannot bill over the PPO allowed amount. Delta Dental Premier and
non-network dentists can bill for charges above the allowed Delta Dental PPO
amount. However, Delta Dental Premier dentists cannot bill for charges above
the allowed Delta Dental Premier amount.
Individual Kids Basic Plan
(Children under age 19 only)
The Individual Kids Basic plan uses an Exclusive Provider Feature where
benefits are paid only when a member uses a Delta Dental PPO dentist. Delta
Dental PPO dentists cannot bill members for charges over the PPO allowed
amount. There are no benefits when a member uses a non-Delta Dental PPO
network dentist. Members under age 19 can use the benefits of both the
Silver and Individual Kids Basic plans, but can only receive benefits from the
Individual Kids Basic plan with Delta Dental PPO dentists.
Deductible
(benefit year; per person, applies to all services)
$75
Deductible
(benefit year; per person, applies to basic and major
services only)
$120
Out-of-Pocket Limit N/A Out-of-Pocket Limit
$350 per
individual
child
Annual Maximum (benefit year) $1,000
Family Out-of-Pocket Limit (for children under age 19)
$700
Covered Dental Services
Preventive Services
• Exams (limited to 2 per person in a benefit year)
• Cleanings (limited to 2 per person in a benefit
year)
• Bitewing X-rays (limited to 1 set per person in a
benefit year)
• X-rays (full mouth/panoramic – limited to 1 per
person in 36 months)
• Fluoride Treatments (limited to 1 per person in a
benefit year, under age 16)
• Space Maintainers (under age 14)
• Sealants (under age 16)
90%
Preventive Services
• Exams (limited to 2 per person in a benefit year)
• Cleanings (limited to 2 per person in a benefit
year)
• Bitewing X-rays (limited to 2 per person in a
benefit year)
• X-rays (full mouth/panoramic – limited to 1 per
person in 36 months)
• Fluoride Treatments (limited to 1 per person in a
benefit year, under age 19)
• Space Maintainers (under age 19)
• Sealants (under age 19)
100%
in-
network/
0%
out-of-
network
Basic Services (6 month waiting period**)
• Fillings/Amalgams
• Simple Extractions
50%
Basic Services
• Fillings/Amalgams
• Simple Extractions
• Gum Disease Treatment
• Root Canals
• Surgical Extractions
50%
in-
network/
0%
out-of-
network
Major Services (12 month waiting period**)
• Gum Disease Treatment
• Root Canals
• Surgical Extractions
• Denture Relines and Rebases, Adjustments
• Repairs to Crowns, Dentures and Bridges
• Crowns
• Complete and Partial Dentures
• Fixed Bridgework
50%
Major Services
• Denture Relines and Rebases, Adjustments
• Repairs to Crowns, Dentures and Bridges
• Crowns
• Complete and Partial Dentures
• Fixed Bridgework
50%
in-
network/
0%
out-of-
network
Enhanced Benefits Program
Oers additional coverage for individuals who have
specific health conditions (including pregnancy,
diabetes, high-risk cardiac conditions and
suppressed immune systems) that can be positively
aected by additional oral health care.
Included
Enhanced Benefits Program
Oers additional coverage for individuals who have
specific health conditions (including pregnancy,
diabetes, high-risk cardiac conditions and
suppressed immune systems) that can be positively
aected by additional oral health care.
Included
Orthodontia
Not
included
Orthodontia (medically necessary orthodontia only)
The ACA requires coverage for medically necessary
orthodontia only. Predeterminations will be
necessary to determine if there is any coverage for
orthodontia under the Individual Kids Basic plan.
50%
in-
network/
0%
out-of-
network
* Single rates are not available for Delta Dental PPO – Gold and Silver plans with Individual Kids Basic Plan; there must be one adult and one or more dependents
enrolled in these plans. Single rates are available for all other plans
** The waiting period is waived if the member was covered under a Delta Dental of Illinois group-sponsored policy within 60 days of the start of coverage under
this policy, and had at least 12 months of continuous coverage under that plan. Waiting periods must be satisfied if there has been a lapse in coverage or for new
members who are added to this policy.
There is a 24-month waiting period to re-enroll if the member drops coverage. Subsequent rate changes will be reviewed prior to the renewal date subject to
a 60-day notification. Applications must be received by the 20th of the month to be eective the 1st of the following month. Applications received after the
20th will be eective the 1st of the month after the next month.
Visit deltadentalil.com/healthalliance for monthly premiums and to enroll members or call 800-323-1743.
5
Individual and Family Plan Options Delta Dental PPO
SM
– Bronze Plan
The Bronze Plan
The Bronze Plan is based on the Delta Dental PPO network.
Delta Dental PPO dentists cannot bill over the PPO allowed amount.
Delta Dental Premier and non-network dentists can bill for charges
above the allowed Delta Dental PPO amount. However, Delta Dental
Premier dentists cannot bill for charges above the allowed Delta
Dental Premier amount.
Deductible (benefit year; per person, applies to
all services)
$25
Annual Maximum (benefit year) $500
Covered Dental Services
Preventive Services
•
Exams (limited to 2 per person in a benefit year)
•
Cleanings (limited to 2 per person in a benefit year)
•
Bitewing X-rays (limited to 1 set per person in a
benefit year)
•
X-rays (full mouth/panoramic – limited to 1 per person
every 36 months)
•
Fluoride Treatments (limited to 1 per person in a
benefit year, under age 18)
•
Space Maintainers are not covered
•
Sealants (under age 19)
100%
Basic Services (6 month waiting period*)
•
Fillings/Amalgams
•
Simple Extractions
Not Covered
Major Services (12 month waiting period*)
•
Gum Disease Treatment
•
Root Canals
•
Surgical Extractions
•
Denture Relines and Rebases, Adjustments
•
Repairs to Crowns, Dentures and Bridges
•
Special Restorative
•
Crowns
•
Complete and Partial Dentures
•
Fixed Bridgework
Not Covered
Enhanced Benefits Program
Oers additional coverage for individuals who have specific
health conditions (including pregnancy, diabetes, high-risk
cardiac conditions and suppressed immune systems) that can
be positively aected by additional oral health care.
Additional general cleanings and fluoride
treatment where applicable
* The waiting period is waived if the member was covered under a Delta Dental of Illinois group-sponsored policy within 60 days of the start of coverage under
this policy, and had at least 12 months of continuous coverage under that plan. Waiting periods must be satisfied if there has been a lapse in coverage or for new
members who are added to this policy.
There is a 24-month waiting period to re-enroll if the member drops coverage. Subsequent rate changes will be reviewed prior to the renewal date subject to
a 60-day notification. Applications must be received by the 20th of the month to be eective the 1st of the following month. Applications received after the
20th will be eective the 1st of the month after the next month.
Visit deltadentalil.com/healthalliance for monthly premiums and to enroll members or call 800-323-1743.
6
Delta Dental of Illinois Individual Kids Basic Plan
(Children under age 19 only)
The Individual Kids Basic plan uses an Exclusive Provider Feature where benefits are paid only when a member uses a Delta Dental
PPO dentist. Delta Dental PPO dentists cannot bill members for charges over the PPO allowed amount. There are no benefits when a
member uses a non-Delta Dental PPO network dentist.
Deductible (benefit year; per person, applies to basic and major services only) $120
Out-of-Pocket Limit $350 per individual child
Family Out-of-Pocket Limit (for children under age 19) $700
Covered Dental Services
Preventive Services
• Exams (limited to 2 per person in a benefit year)
• Cleanings (limited to 2 per person in a benefit year)
• Bitewing X-rays (limited to 2 per person in a benefit year)
• X-rays (full mouth/panoramic – limited to 1 per person in 36 months)
• Fluoride Treatments (limited to 1 per person in a benefit year, under age 19)
• Space Maintainers (under age 19)
• Sealants (under age 19)
100% in-network/
0% out-of-network
Basic Services
• Fillings/Amalgams
• Simple Extractions
• Gum Disease Treatment
• Root Canals
• Surgical Extractions
50% in-network/
0% out-of-network
Major Services
• Denture Relines and Rebases, Adjustments
• Repairs to Crowns, Dentures and Bridges
• Crowns
• Complete and Partial Dentures
• Fixed Bridgework
50% in-network/
0% out-of-network
Enhanced Benefits Program
Oers additional coverage for individuals who have specific health conditions (including
pregnancy, diabetes, high-risk cardiac conditions and suppressed immune systems) that
can be positively aected by additional oral health care.
Included
Orthodontia (medically necessary orthodontia only)
The ACA requires coverage for medically necessary orthodontia only. Predeterminations will be necessary to
determine if there is any coverage for orthodontia under the Individual Kids Basic plan.
50% in-network/
0% out-of-network
Visit deltadentalil.com/healthalliance for monthly premiums and to enroll members or call 800-323-1743.
Delta Dental of Illinois
800-323-1743
deltadentalil.com/healthalliance
Smart plans for smart mouths.
© 11/2014
6375HA (8/16)
