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FACCC |
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Delta Dental Insurance |
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FACCC
membership required
Become a
member now
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Faculty Association of California Community College
Welcome to Delta Dental
DELTA DENTAL PPO
DELTACARE USA HMO
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Print Fill Out and Fax to
209-579-0399 |
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| Highlights of Coverage | How The Plan Works | -
PPO
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HMO
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FAMILY COVERAGE
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FULL OR PART TIME
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Guaranteed ISSUED
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Provider Directory |
| HMO
SOUTHERN CAL.
HMO NORTHERN CAL. |
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Affordable Group
Dental Rates |
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Rates For PPO |
Monthly rates |
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Guaranteed |
Two year |
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One Party |
$39.85 |
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Two Party |
$71.44 |
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Three Party+ |
$120.28 |
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Rates For
HMO |
Monthly rates |
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Guaranteed |
Two year |
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One Party |
$18.16 |
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Two Party |
$29.97 |
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Three Party+ |
$44.32 |
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DeltaCare |
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How your DeltaCare®
USA program works:
Your selected
contract dentist will take care of your dental care needs. If you
require treatment from a specialist, your contract dentist will
handle the referral for you. After you have enrolled, you will
receive a membership packet including an identification card and an
Evidence of Coverage booklet that fully describes the benefits of
your dental program.
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| How
to select a DeltaCare® USA dentist:
You select a
dentist from the attached provider list. DeltaCare® USA
dentists pass stringent reviews for quality, access and safety
before joining the network. Delta Dental maintains quality
standards by visiting each general dental office regularly.
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My
dentist is a Delta Dental dentist but is not on the list of
DeltaCare® USA dentists. Can I still receive treatment
from this dentist?
You must
receive treatment from your selected DeltaCare®
USA contract dentist. Please note that Delta Dental dentists are
not necessarily DeltaCare® USA dentists |
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Do my
family members receive treatment from the same DeltaCare®
USA contract dentist?
You and your
eligible dependents may receive care from the same contract dentist,
or if you prefer, you may collectively select up to a maximum of
three individual contract dental facilities.
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Can I
change my contract dentist?
You may change
contract dentists by notifying us either by phone (800-422-4234) or
in writing, or by visiting our online provider directory web site (www.deltadentalins.com).
If you contact us by the 21st of the month, the change
will become effective the first of the following month. |
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Procedures |
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Dental Procedures Covered by The
HMO |
Listed
below are some of the common dental procedures covered by your
DeltaCare® USA dental program. An Evidence of Coverage
booklet that fully describes the benefits of your dental program
will be sent to you.
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Procedure code |
Procedure |
Patient Copayment |
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D0999 |
Office Visit |
No Cost |
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D0210 |
X-Rays |
No Cost |
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D1110 |
Adult cleanings |
No Cost |
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C2140-61 |
Fillings (Amalgams) |
No Cost |
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D2391-95 |
Fillings (Resin-based posterior composites) |
$55-$85 |
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D2750 |
Crown (porcelain fused to high noble metal) |
$240 |
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D3330 |
Molar root canal |
$250 |
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D4260 |
Osseous surgery |
$280 |
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D4341 |
Scaling & root planing |
$25 |
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D5110-20 |
Complete denture (upper & lower) |
$145 |
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D7111 |
Simple extraction |
No Cost |
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D7230 |
Removal of impacted tooth (partially bony) |
$70 |
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D8070 |
Comprehensive orthodontics (child) |
$1,700 |
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D9220 |
General anesthesia (first 30 minutes) |
$165 |
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D9940 |
Occlusal guard |
$100 |
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39972 |
External bleaching (per arch) |
$125 |
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Plan Advantages |
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| Portable -
unlike coverage
through an
employer, once you have been covered for 2 years this plan
will not terminate if you change jobs! | | | | | | | |
Payment
Options -
include quarterly,simi
annual,and annualy. |
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| Underwritten By |
| Delta
Dental |
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DeltaCare USA is our prepaid plan that
features set copayments, no annual deductibles and no maximums
for covered benefits. In most states, enrollees must select a
primary care dentist in the DeltaCare USA network from whom they
receive treatment as in a traditional DHMO. In some states,
DeltaCare USA is offered as an open access plan where enrollees
can obtain treatment from any licensed dentist; however,
deductibles and maximums may be applied to out-of-network
treatment.
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