INPPOSUM1122 KR#05809057 Porcelain and resin facings on crowns are Covered Services on posterior teeth. Implants are payable once per tooth in any five-year period. Implant related services are Covered Services. Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. People with special health care needs may be eligible for additional services including exams, hygiene visits, dental case management, and sedation/anesthesia. Special health care needs includes any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, healthcare intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of Dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our website or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment $500 per Member total per Benefit Year on all services except orthodontic services. $1,000 per Member total per lifetime on orthodontic services. Payment for Orthodontic Service When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 50% of the per month fee charged by your Dentist based upon the agreed upon payment plan provided by Delta Dental to your Dentist. Deductible None. Waiting Period Enrollees who are eligible for dental benefits are covered on the date of hire. Not applicable (0002, 0099) Eligible People All full-time and part-time employees of the Contractor as defined by The Jay County School Corporation (0001), all eligible retirees as defined by The Jay County School Corporation (0002) who choose the dental plan and COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees (0099). Also eligible are your Spouse and your Children to the end of the calendar year in which they turn 26, including your Children who are married, who no longer live with you, who are not your dependents for Federal income tax purposes, and/or who are not permanently disabled. Enrollees and dependents choosing this plan are required to remain enrolled for a minimum of 12 months. Should an Enrollee or Dependent choose to drop coverage after that time, he or she may not re-enroll prior to the date on which 12 months have elapsed. Dependents may only enroll if the Enrollee is enrolled (except under COBRA) and must be enrolled in the same plan as the Enrollee. An election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. Coordination of Benefits If you and your Spouse are both eligible to enroll in This Plan as Enrollees, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate Benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Enrollees under This Plan. Benefits will cease for active employees at the end of the month from the date of termination of employment. Benefits for retirees will cease on the first day of the month of their 65th birthday. Customer Service Toll-Free Number: 800-524-0149 (TTY users call 711) https://www.DeltaDentalIN.com September 1, 2023