Plan
Plan Name:
DeltaCare USA Basic Plan for Families NS INN Dep 25 Family Dental
Issuer Name:
Delta Dental of New York, Inc
HIOS ID:
10345NY0030009
Annual Benefit Maximum:
N/A
Out of Network Coverage:
N
Dental Plan Type
Dental Plan Type:
Adult & Family Dental Plan
Plan Information
Dep Age:
Age 25
Plan Type:
HMO
Standard or Non-Standard Plan:
Non-Standard
Waiting Periods:
No
Deductible Adult Individual:
N/A
Limit Description:
Pediatric: Two (2) dental exams & cleanings per 12 months; Full mouth X-rays or panoramic X-rays at 36 month intervals; bitewing X-rays at six month intervals; Additional details for Pediatric and Adult listed in Contract
Limits on Services:
Yes
Lifetime Benefit Maximum:
N/A
Coverage Level:
Couple
Benefits Excluded from In Network MOOP:
Listed in Contract
FDP In Network Cost Sharing Adult Benefits
FDP Office Visit With No Additional Services - Adult:
CP: $20
FDP Oral Evaluation - Adult:
CP: $5
FDP Complete Set of X-Rays - Adult:
CP: $20
FDP Topical Fluoride - Adult:
CP: $5
FDP Polishing - Adult:
CP: $15
FDP Sealant (per tooth) - Adult:
CI: N/A
FDP Spacers - Adult:
CI: N/A
FDP Simple Extraction - Adult:
CP: $75
FDP Fillings - Adult:
CP: $75
FDP Single Restoration Crowns - Adult:
CP: $350
FDP Pulp Cap - Adult:
CP: $20
FDP Bonding - Adult:
CP: $80
FDP Root Canal - Adult:
CP: $350
FDP In Network Cost Sharing Adult Benefits
FDP MOOP Adult Individual:
None
FDP Deductible 2+ Adult Members:
N/A
FDP MOOP 2+ Members:
None
FDP Additional In Network Cost Sharing Adult Benefits
FDPA Scaling - Adult:
CP: $70
FDPA Gingivectomy or Gingivoplasty - Adult:
CP: $220
FDPA Gum Surgery - Adult:
CP: $550
FDPA Routine Braces - Adult:
CP: $3250
FDPA Partial Dentures - Adult:
CP: $350
FDPA Complete Dentures - Adult:
CP: $350
FDPA Dental Implants - Adults:
Not covered
FDPA Bridges - Adults:
CP: $350
FDPA Veneers - Adult:
CP: $335
FDPA TMJ - Adult:
CP: $350
FDP In Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual:
N/A
FDP MOOP Pediatric Individual:
$400
FDP Deductible Pediatric 2+ Children:
N/A
FDP MOOP Pediatric 2+ Children:
$800
FDP Dental Check-Up - Child:
CP: $0
FDP Basic Dental Care - Child:
CP: $85
FDP Orthodontia - Child:
CP: $350
FDP Cosmetic Orthodontia - Child:
Not covered
FDP Major Dental Care - Child:
CP: $350
FDP Out of Network Cost Sharing Adult Benefits
FDP Deductible Adult Individual (Out of Network Cost Sharing Adult Benefits):
N/A
FDP MOOP Adult Individual (Out of Network Cost Sharing Adult Benefits):
None
FDP Deductible 2+ Members (Out of Network Cost Sharing Adult Benefits):
N/A
FDP MOOP 2+ Members (Out of Network Cost Sharing Adult Benefits):
None
FDP Office Visit With No Additional Services - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Oral Evaluation - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Complete Set of X-Rays - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Prophylaxis - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Topical Fluoride - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Polishing - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Sealant (per tooth) - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Spacers - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Simple Extraction - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Fillings - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Single Restoration Crowns - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Pulp Cap - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Bonding - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Root Canal - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Scaling - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Additional Out of Network Cost Sharing Adult Benefits
FDP Gingivectomy or Gingivoplasty - Adult:
Not covered
FDP Gum Surgery - Adult:
Not covered
FDP Tissue Grafting - Adult:
Not covered
FDP Routine Braces - Adult:
Not covered
FDP Partial Dentures - Adult:
Not covered
FDP Complete Dentures - Adult:
Not covered
FDP Dental Implants - Adults:
Not covered
FDP Bridges - Adults:
Not covered
FDP Veneers - Adult:
Not covered
FDP TMJ - Adult:
Not covered
FDP Out of Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
N/A
FDP MOOP Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Deductible Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
N/A
FDP MOOP Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Dental Check-Up - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Basic Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Cosmetic Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Major Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Network Information (Family Dental)
FDP Out of Country Coverage:
N
FDP Out of Country Coverage Description:
N/A
FDP Out of Service Area Coverage:
N
FDP Out of Service Area Coverage Description:
N/A
FDP National Network:
N
FDP Network Name:
DeltaCare USA
FDP Network URL:
Counties
Cayuga:
$40.69
Cortland:
$40.69
Genesee:
$40.69
Kings:
$40.69
Nassau:
$40.69
New York:
$40.69
Oswego:
$40.69
Queens:
$40.69
Rensselaer:
$40.69
Rockland:
$40.69
Suffolk:
$40.69
Tompkins:
$40.69
Westchester:
$40.69