Summary of Material Modifications (SMM) - Unite Here Health
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September 2020
Summary of Material Modification
Modifications (SMM)
This is a Summary of Material Modifications (SMM). It explains some of the changes and additions made to your
benefits by the Board of Trustees of UNITE HERE HEALTH (UHH). These updates affect the information in your
Summary Plan Description (SPD).
Please read this information carefully so that you understand your benefits. Be sure to keep this with your
SPD. If you have any questions about your benefits, please call the Hospitality Plan Customer Service Office at
855-405-3863.
To protect you and your dependents during the coronavirus (COVID-19) pandemic, the Trustees have
approved temporary changes to your benefits and eligibility. You will be notified when these temporary
special benefits end. This SMM provides updates to programs the Fund previously announced. Because
of the pandemic, you generally have more time to do certain things, like file or appeal a claim, enroll your
new dependent, or elect COBRA and make COBRA self-payments. Call us for more information.
The Trustees have also approved other changes in your benefits (unrelated to COVID-19), also described
in this SMM. The changes described in this SMM also affect your Summary of Benefits and Coverage
(SBC). Remember, you can always get a copy of your SBC by calling the Fund.
Your Fund is taking care of you!
As of March 9, 2020, through the end of the COVID-19 national emergency as declared
by the Department of Health and Human Services, you will not pay any cost-sharing
(copays, deductibles, or coinsurance) for medically appropriate testing or medically
necessary treatment for the coronavirus (COVID-19).
You pay no cost-sharing for any medically appropriate network or non-network testing for COVID-19
that is ordered by a healthcare provider. (“Testing” includes both tests to determine if you currently
have the virus, or if you have antibodies to the virus.) In addition, if the primary purpose is to get the
testing, you will not pay any cost-sharing for items and services related to the test, including, for example,
in-person or telehealth office visits, urgent care center visits, and emergency room visits. However, your
normal cost-sharing applies to visits, items, and services (other than the COVID-19 test), if the primary
purpose of your visit isn’t to get or determine if you need to get a COVID-19 test.
You will also not pay any cost-sharing for medically necessary treatment of COVID-19.
All other Plan rules remain in effect, including what’s not covered. Remember, the Fund will not pay amounts
over the allowable charge – if you use a non-network provider, you may have to pay those amounts even
though you won’t have to pay your cost-sharing.
September 2020 SMM | Hospitality Plan Unit 185 Page 1 of 22September 2020
Your Fund is taking care of you! (continued)
As of March 19, 2020, you will not pay anything out-of-pocket for network telehealth
office visits.
Many healthcare providers are encouraging patients not to leave their home and to instead call or
schedule a video appointment. If your provider offers phone or video (telehealth) visits, the Fund will cover
those visits. This means if you use a network provider, you will not pay anything out-of-pocket ($0 copay) for
the telehealth visit (as long as the Fund would have covered the same service through an in-person visit).
However, if you use a non-network provider for telehealth visits, all the non-network benefits, cost-sharing
and other rules apply.
As of March 19, 2020, you will not pay anything out-of-pocket for Teladoc telehealth visits.
The Fund is temporarily waiving the $15 copay for all video or phone visits with a Teladoc healthcare
professional. This means you will not have to pay the copays listed on page 3 of this SMM for the
Teladoc services.
Don’t forget to use the mail-order pharmacy for your long-term drugs! Why?
• You can usually save money.
• Your drugs will be shipped directly to you – you won’t have to leave home.
Call HospitalityRx at 844-813-3860 if you need help getting your prescription drugs.
September 2020 SMM | Hospitality Plan Unit 185 Page 2 of 22September 2020
Medical Benefits
Mammogram screening
As of January 1, 2020, under Preventive Healthcare, when you use a network provider, you can get a
routine mammogram screening with no copay earlier!
• One per calendar year for all women age 35 and older
• One per calendar year for women under age 35 who are at high risk for breast cancer
Cervical cancer screening
As of January 1, 2020, under Preventive Healthcare, when you use a network provider, your preventive
cervical cancer screening (pap smears) and HPV screenings are covered annually at all ages with
no copay.
New telehealth provider!
As of January 1, 2020, telehealth services are provided by Teladoc instead of Doctor on Demand.
Your copay will stay the same at $15.
Teladoc
1-800-835-2362
www.teladoc.com
You can use computers or mobile devices (smart phones, tablets) for phone or video visits with a
board-certified doctor. This means you can see a doctor even if you can’t go to an office.
Some reasons to use Teladoc:
• Sore throat • Dermatology (skin) issues
• Fever and flu (Upload images of a skin issue and get a custom
• Sinus problems and allergies treatment plan within 2 days.)
• Vomiting and diarrhea • Pediatric care
• Get a prescription • Behavioral health visits
How to use Teladoc:
• Visit teladoc.com
• Set up your account and follow the instructions
• Video visit with doctors
September 2020 SMM | Hospitality Plan Unit 185 Page 3 of 22September 2020
Life and AD&D Benefits
Life Insurance and AD&D vendor name change
As of January 1, 2020, the name of Dearborn National has changed. It’s now called Blue Cross Blue
Shield of Illinois. You may still see the name Dearborn National on certain forms, etc.
Dental Benefits
New dental provider!
As of January 1, 2020, there is a new provider for dental services. Your dental benefits will be
provided by Delta Dental of Illinois instead of Cigna for both the DHMO and the PPO.
Delta Dental of Illinois Partners with DeltaCare DHMO
1-800-422-4234
www.deltadentalins.com/deltacare
Delta Dental of Illinois (Delta Dental PPO)
1-800-323-1743
www.deltadentalil.com
DeltaCare DHMO
UNITE HERE HEALTH has contracted with Delta Dental of Illinois to provide dental benefits to you
and your dependents, if you choose this benefit option. This part of the SMM summarizes your
dental benefits. You’ll be given a detailed document that also lists any other type of dependents
you can enroll in dental coverage, in addition to the dependents listed in your Summary Plan
Description (SPD). The rules about who your dependent is under the Delta DHMO dental benefits
only apply to DHMO dental benefits, and do not apply to any other benefits offered under the
Plan. Call UNITE HERE HEALTH at 833-637-3519 if you need help understanding what dependents
are eligible for Delta Dental coverage, since UNITE HERE HEALTH makes all eligibility decisions.
If there is any conflict between the SPD and Delta documents, which contain certain state-specific
rules about benefits and cost-sharing, the terms of the Delta documents govern. If you have any
questions about dental benefits, please contact Delta Dental of Illinois.
Delta Dental of Illinois Partners with DeltaCare DHMO
800-422-4234
www.deltadentalins.com/deltacare
September 2020 SMM | Hospitality Plan Unit 185 Page 4 of 22September 2020
Dental Benefits (continued)
DeltaCare DHMO (continued)
Benefits are only payable if you use your assigned DeltaCare dentist. In most states, you’re required to have
an assigned dentist. But some states don’t require an assigned dentist. For example, if you live in Mississippi,
you will not have an assigned dentist. In these states, you can get dental care from any DeltaCare dentist.
See “Your primary dentist,” on page 6 for more information.
Your copay depends on the type of dental care you get. The table below shows the copays for some of
the more common dental procedures.
DeltaCare DHMO
Benefit Feature What You Pay
Calendar year deductible None
Maximum benefit per person No maximum. There is no limit on the
benefits paid for your dental care each year.
Oral exam No copay
Most x-rays No copay
Regular periodic cleaning for adult or child No copay
prophylaxis (1 per 6 month period)
Topical application of fluoride No copay
for children up to age 19 (1 per 6 month period)
Sealants for children under age 16 $5 copay per tooth
Periodontal scaling and root planing No copay
(4 quadrants total per year)
Periodontal maintenance (1 per 6 month period) No copay
Amalgam fillings No copay
Onlays (metallic) No copay
Crowns $35 - $195 copay (depending on type of crown)
Gingevectomy or gingivoplasty $50 - $80 copay (depending on teeth per quadrant)
Pulp cap No copay
Root canal $45 - $220 copay (depending on type of root canal)
Complete denture (upper or lower) every 5 years $100 copay per denture
Denture reline or rebase $0 - $35 copay (depending on type of repair)
(1 per denture each year)
Removal of impacted tooth $25 - $90 copay (depending on type of removal)
Comprehensive orthodontia for children under $1,700
age of 19 (2 years of treatment)
Comprehensive orthodontia for adults $1,900
(2 years of treatment)
September 2020 SMM | Hospitality Plan Unit 185 Page 5 of 22September 2020
Dental Benefits (continued)
Using Your Benefits - DeltaCare DHMO
Your dental benefits are provided through a dental health maintenance organization (DHMO).
Under a DHMO, you must follow certain rules in order to get dental benefits. If you don’t follow
these rules, you may have to pay the entire cost of the dental care yourself. If you have any questions about
how to use your dental benefits, please contact DeltaCare USA at 800-422-4234.
Your Primary Dentist
Do I have to choose a primary dentist?
Generally, you must pick a primary dentist and use your assigned DeltaCare primary dentist. If you go to a
different dentist than your assigned one, benefits are not payable. However, the Plan may differ by state.
Some states (what Delta refers to as Open Access) don’t require an assigned dentist. For example, if you live
in Mississippi you’re not required to use an assigned dentist. See last paragraph for more details.
What dentists can I choose?
• You can pick any dentist in the DeltaCare USA network who is taking new patients.
• You don’t have to pick the same primary dentist as your dependents.
For example, you and your spouse can use one primary dentist while your children use another dentist.
Can I change my primary dentist?
• Yes! You can change your primary dentist any time you want, and as often as you want.
• If you change your dentist by the 20th of the month, you can start going to your new dentist the
beginning of the next month.
• If you change your dentist on or after the 21st, you’ll have to wait unit the start of the second month.
For example:
• If you change your primary dentist on April 20, you can go to your new dentist on May 1.
• If you change your primary dentist on April 21, you can go to your new dentist on June 1.
How do I choose or change my primary dentist?
• Log on to www.deltadentalins.com/deltacare or
• Call DeltaCare at 800-422-4234
What if I have a dental emergency?
• If you experience a dental emergency, please contact your assigned DeltaCare dentist.
• If you’re unable to reach the assigned dentist, please call DeltaCare at 800-422-4234.
• If you’re unable to reach the assigned dentist and the emergency is after DeltaCare’s hours, you may
seek emergency treatment from another dentist. However, benefits payable may be limited. Further
treatment must be obtained from the assigned dentist.
What if I live in a state that doesn’t require an assigned dentist?
• If you live in an Open Access state, you can use any licensed dentist in the DeltaCare USA network.
• Please refer to the Evidence of Coverage (EOC) certificate and/or call DeltaCare at 800-422-4234
for any questions.
September 2020 SMM | Hospitality Plan Unit 185 Page 6 of 22September 2020 Dental Benefits (continued) Using Your Benefits - DeltaCare DHMO How Open Access works: • Login to www.deltadentalins.com/deltacare • Search using the DeltaCare USA network • Contact the dentist to make an appointment • No referral required for specialty or emergency care • Change your dentist at any time (select a DeltaCare USA Network dentist). You don’t need to contact DeltaCare to make this change. What you pay With your DeltaCare USA plan, some services are covered at no cost, while others have a copayment (amount you pay) for certain services. Review your Evidence/ Certificate of Coverage (EOC) for a list of covered services and copayments. If you have any questions about the charges for a service, please contact DeltaCare at 800-422-4234. If you receive treatment that requires a copayment, simply pay the dental facility at the time of service. The copayment shown on your DeltaCare EOC fee schedules is your share of the cost for covered benefits when provided by a DeltaCare dentist. What’s covered Covered Expenses means all Allowable Charges made by a dentist for the types of services and supplies listed below. In order to be considered a covered expense, Delta Dental must determine that the service or supply was based on a valid dental need and performed according to accepted standards of dental practice. There are limits on how often certain services and supplies are covered. If the amount of time shown below has not passed since the service or supply was last provided, you may have to pay 100% of the cost. You may contact DeltaCare at 800-422-4234 to find out the last date for services rendered by a specialist. Please contact your primary dentist regarding general dentist services. The types of services and supplies that are covered are listed on the next page. The DeltaCare EOC contains more specific information about: • What’s covered • How frequently • Any age restrictions and • Your cost-sharing September 2020 SMM | Hospitality Plan Unit 185 Page 7 of 22
September 2020
Dental Benefits (continued)
What’s covered (continued)
The Plan only pays benefits for these types of expenses:
• Diagnostic and preventive services and procedures
To evaluate existing conditions and/or to prevent the occurrence of dental abnormalities or disease,
including periodic exams and cleanings:
◦ Oral exams
◦ Routine cleanings (1 every 6 months)
◦ Full mouth, panoramic x-rays (1 every 5 years)
◦ Bitewing x-rays (1 series every 6 months)
◦ Topical application of fluoride for dependent children under age 19 (1treatment every 6 months)
◦ Sealants applied once per tooth (only permanent molars through age 15)
◦ Space maintainers
◦ Re-cementation or re-bond of space maintainers
◦ Palliative (emergency) treatment of pain
◦ Consultation
• Restorative services
Includes polishing all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch
procedures and crowns:
◦ Amalgam and resin-based fillings
◦ Onlays (metallic, porcelain/ceramic, and resin-based composite)
◦ Crowns and ceramic restorations
◦ Recementation of inlays, onlays, veneer, crown, partial coverage restorations, indirectly fabricated
or prefabricated posts and cores
◦ Prefabricated stainless steel crowns
◦ Pin retention
◦ Prefabricated post and core; core build-up
• Endodontic services and procedures
For the treatment of teeth with diseased or damaged nerves including:
◦ Pulp caps
◦ Therapeutic pulpotomy
◦ Root canals
◦ Apicoectomy
◦ Periadicular surgery
◦ Retrograde filling
◦ Pulpal therapy (resorbable filling)
September 2020 SMM | Hospitality Plan Unit 185 Page 8 of 22September 2020
Dental Benefits (continued)
What’s covered (continued)
• Periodontic services
For treatment for disease of the gums and bone supporting the teeth:
◦ Periodontal scaling and root planing (Up to 4 quadrants per year)
◦ Full mouth debridement to enable comprehensive evaluation and diagnosis
(1treatment per year)
◦ Periodontal maintenance (1 treatment every 6 months)
◦ Gingivectomy or gingivoplasty; gingival flap procedure
◦ Clinical crown lengthening (hard tissue)
◦ Osseous surgery (including elevation of a full thickness flap and closure)
◦ Bone replacement graft
◦ Free soft tissue graft procedures
• Oral surgery
Extractions and other listed oral surgery procedures (including pre and post-operative care) only
when provided in a dentist office:
◦ Extraction, coronal remnants (primary tooth)
◦ Extraction, erupted tooth
◦ Removal of impacted tooth (soft tissue)
◦ Tooth reimplantation/stabilization of accidentally evulsed or displaced tooth
◦ Exposure of an unerupted tooth
◦ Incisional biopsy of oral tissue
◦ Alveoloplasty
◦ Removal of exostosis, torus platinus or torus mandibularis
◦ Incision and drainage of abscess (intraoral soft tissue)
◦ Frenulectomy or frenulopasty
◦ Excision of hyperplastic tissue or pericoronal gingiva
• Prosthodontic (removable):
Services, procedures, and appliances that replace missing natural teeth, including bridges and
partial and complete dentures:
◦ Complete and partial dentures (maxillary)
◦ Complete and partial dentures (mandibular)
◦ Denture rebase
◦ Denture reline
◦ Replace missing or broken teeth
◦ Repairs to complete and partial dentures
◦ Replace all teeth and acrylic on cast metal framework
◦ Add tooth or clasp to existing partial denture
September 2020 SMM | Hospitality Plan Unit 185 Page 9 of 22September 2020
Dental Benefits (continued)
What’s covered (continued)
• Prosthodontic (fixed):
Repairs to prosthetic appliances:
◦ Pontic
◦ Retainer (inlays, onlays and crowns)
◦ Re-cement or re-bond fixed partial denture
◦ Fixed partial dentures repair necessitated by restorative material failure
• Orthodontic services
Treatment necessary for proper alignment of teeth, Orthodontic workup, including x-rays, diagnostic
tests, casts and treatment, and the first 2 years of active treatment, including all active treatment and
retention appliance.
◦ Continued active treatment up to 2 years.
What’s not covered
Unless required by state law, the following types of treatments, services, and supplies aren’t covered:
• Any procedure not specifically listed as covered under the DeltaCare DHMO
Evidence of Coverage (EOC)
• Any procedure that in the professional opinion of the treating Dentist:
◦ Has poor prognosis for a successful result and reasonable longevity based on the condition of the
tooth or teeth and/or surrounding structures, or
◦ Is inconsistent with generally accepted standards for dentistry
• Services solely for cosmetic purposes, with the exception of external bleaching for home application,
per arch, or for conditions that are a result of hereditary or developmental defects, such as cleft
palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored
or lacking enamel, except for the treatment of newborn children with congenital defects or
birth abnormalities
• Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed
partial dentures (bridges) for children under 16 year of age
• Lost or stolen appliances, including, but not limited to, full or partial dentures, space maintainers,
crowns and fixed partial dentures (bridges)
• Procedures, appliances or restoration if the purpose is to change vertical dimension or to diagnose or
treat abnormal conditions of the temporomandibular joint (TMJ)
• Precious metal for removable appliances, metallic or permanent soft bases for complete dentures,
porcelain denture teeth, precious abutments for removable partials or fixed partial dentures (overlays,
implants, and appliances associated therewith) and personalization and characterization of complete
and partial dentures
September 2020 SMM | Hospitality Plan Unit 185 Page 10 of 22September 2020 Dental Benefits (continued) What’s not covered (continued) • Implant-supported dental appliances and attachments, implants placement, maintenance, removal and all other services associated with a dental implant. Please note, although dental implants and most associated procedures are not covered, DeltaCare does include coverage for crowns over an implant. Please contact DeltaCare at 800-422-4234 with questions. • Consultations for non-covered benefits • Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a Contract Orthodontist except for Emergency Services as described in the Contract and/or Evidence of Coverage • All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility • Prescription drugs • Dental expenses incurred in connection with any dental or orthodontic procedure started before the employee’s eligibility with DeltaCare USA Program. Examples include: teeth prepared for crowns, root canals or progress, full or partial dentures for which an impression has been taken and orthodontics unless qualified for the orthodontic treatment in progress provision. • Lost, stolen or broken orthodontic appliances • Changes in orthodontic treatment necessitated by accident of any kind • Myofunctional and parafunctional appliances and/or therapies • Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances • Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services Delta Dental DHMO and your SPD The parts of your SPD that govern coordination of benefits, subrogation, general exclusions and limitations, claim filing and appeal provisions, and definitions do not apply to the DHMO benefits provided under the contract with DeltaCare. Please call DeltaCare at 800-422-4234 or refer to your DeltaCare EOC for more information on these topics. When you have questions about getting prior authorization, or if you need help filing a claim or appeal, call DeltaCare at 800-422-4234. September 2020 SMM | Hospitality Plan Unit 185 Page 11 of 22
September 2020
Dental Benefits (continued)
Annual benefit maximum increased under the Dental PPO!
As of January 1, 2020, your annual maximum benefit amount is $2,000. It used to be $1,500.
The Delta Dental PPO plan lets you choose which dentist you want to go to. But, the amount you pay for
your dental care depends on your dentist. You will save the most money if you go to a Delta Dental PPO
dentist. Services received from a non-network dentist will be covered up to the Maximum Plan Allowance
(MPA). However, the dentist can send you a balance bill for any charges over the MPA. You can use a Delta
Dental Premier Dentist to lower your costs. These dentists can’t balance bill you. If you have any questions
about how your dental benefits work, please contact Delta Dental of Illinois.
Delta Dental of Illinois
800-323-1743
www.deltadentalil.com
Delta Dental PPO
Benefit Feature What You Pay
Delta Dental Delta Dental Non-network
PPO Dentist Premier Dentist* Dentist*
Calendar year deductible $50 per person; $150 per family
Lifetime maximum for orthodontic care $2,500
Maximum benefit per calendar year for
$2,000
non-orthodontic dental care
Diagnostic & preventive
100% 70% 70%
(deductible doesn’t apply)
General services (deductible doesn’t apply) 100% 70% 70%
Basic restorative 80% 60% 60%
Endodontic services 80% 60% 60%
Periodontic services 80% 60% 60%
Oral surgery 80% 60% 60%
Major restorative 50% 40% 40%
Prosthodontic services 50% 40% 40%
Prosthodontic maintenance 80% 60% 60%
Orthodontic care for adults and dependent
50% 50% 50%
children to age 26 (deductible doesn’t apply)
Implants and harmful habit appliances 50% 40% 40%
*For participants living in Louisiana, Mississippi and Texas, the Delta Dental Premier and non-network benefits
will be the same as the PPO benefits.
September 2020 SMM | Hospitality Plan Unit 185 Page 12 of 22September 2020
Dental Benefits (continued)
What’s covered under the Delta Dental PPO?
Covered Expenses means all Allowable Charges made by a dentist for the types of services and supplies
listed below. In order to be considered a covered expense, Delta Dental must determine that the service or
supply was based on a valid dental need and performed according to accepted standard of dental practice.
There are limits on how often certain services and supplies are covered. If the amount of time shown below
has not passed since the service or supply was last provided, you may have to pay 100% of the cost. You
can always contact Delta Dental of Illinois to find out the last time you got benefits for a certain service
or supply. A time limit starts on the date you last got the service or supply. Time limits are measured in
consecutive months or years.
• Diagnostic and preventive services and procedures
Services and procedures to evaluate existing conditions and/or to prevent the occurrence of dental
abnormalities or disease, including periodic examinations and prophylaxes, and consultations with a
non-treating Healthcare Professional
◦ Oral exams, includes limited, problem-focused and re-evaluation
◦ Comprehensive oral exams for new or established patient (once per Dentist)
◦ Detailed and extensive oral exam (problem focused, by report) (once per Dentist)
◦ Comprehensive periodontal exam for new or established patient (once per Dentist)
◦ X-rays as required or in conjunction with the diagnosis of a specific condition:
▪ Bitewing x-rays (2 per Calendar Year)
▪ Full mouth x-rays, which include bitewing x-rays (once every 5 years). A panographic x-ray
(including bitewings) is considered a full mouth x-ray.
◦ Diagnostic casts (when rendered more than 30 days prior to definitive treatment)
◦ Pulp vitality tests (once per visit)
◦ Periodic oral exams (2 per Calendar Year)
◦ Dental prophylaxes, cleaning (2 per Calendar Year)
▪ Additional cleanings may be available for certain conditions in accordance with the
Delta Dental of Illinois’ administrative practice.
◦ Topical application of fluoride for Dependent children under age 19 (twice per Calendar Year)
▪ Application of fluoride may also be available for Persons with certain conditions in accordance
with the Delta Dental of Illinois’ administrative practice.
◦ Sealants applied on a posterior tooth for Dependent children under age 16 (once per tooth
per lifetime)
◦ Space maintainers for Dependent children under age 14 (once per lifetime)
◦ Recementation of space maintainers for Dependent children under age 19 (once per lifetime)
◦ Emergency Palliative Treatment (treatment of dental pain, minor procedure)
◦ Consultations
September 2020 SMM | Hospitality Plan Unit 185 Page 13 of 22September 2020
Dental Benefits (continued)
What’s covered under the Delta Dental PPO? (continued)
• Basic restorative services
Amalgam and resin-based composite fillings (1 per surface every year)
• Endodontic services
Services and procedures for the treatment of teeth with diseased or damaged nerves:
◦ Pulpal therapy, resorbable filling (once per tooth per lifetime)
• Periodontic services
Treatment for disease of the gums and bone supporting the teeth once per quadrant in any
2 years:
◦ Periodontal scaling and root planing
◦ Full mouth debridement to enable comprehensive evaluation and diagnosis (1 per lifetime)
◦ Periodontal maintenance (2 per Calendar Year)
▪ Additional cleanings [or fluoride treatments] may be available for certain conditions in
accordance with the Delta Dental of Illinois’ administrative practice
◦ Surgical periodontics (services are only covered when performed in association with
natural teeth)
◦ Gingivectomy or gingivoplasty; gingival flap procedure
◦ Clinical crown lengthening (hard tissue)
◦ Osseous surgery (including flap entry and closure)
◦ Guided tissue regeneration (per site)
◦ Bone replacement and soft tissue grafts
• Major restorative services
Crowns, jackets, and restorations involving gold when the teeth can’t be restored with another
filling material:
◦ Onlays (permanent teeth only)
◦ Crowns and ceramic restorations (permanent teeth only)
◦ Recementation of inlays, onlays, partial coverage restorations, cast or prefabricated posts and
cores and crowns
◦ Prefabricated stainless steel crowns for Persons under age 12.
◦ Sedative filling (1 per tooth per lifetime)
◦ Crown repair
◦ Pin retention
◦ Cast or prefabricated post and core; core build-up
◦ Post removal
◦ Harmful habit appliance (1 per lifetime)
◦ Athletic mouth guards (1 per 2 years)
September 2020 SMM | Hospitality Plan Unit 185 Page 14 of 22September 2020
Dental Benefits (continued)
What’s covered under the Delta Dental PPO? (continued)
• Oral surgery
Extractions and other listed oral surgery procedures (including pre and post-operative care) only
when provided in a dentist office.
◦ Simple extractions
◦ Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of
bone and/or section of tooth
◦ Removal of impacted tooth (soft tissue)
◦ Removal of impacted tooth (partially bony)
◦ Removal of impacted tooth (completely bony)
◦ Tooth reimplantation/stabilization of accidentally evulsed or displaced tooth and/or alveolus
◦ Surgical access of an unerupted tooth
◦ Biopsy of oral tissue; brush biopsy
◦ Alveoloplasty (per quadrant)
◦ Surgical excision of soft tissue lesions
◦ Surgical excision of intra-osseous lesions
◦ Removal of exostosis, torus platinus or torus mandibularis
◦ Incision and drainage of abscess (intraoral soft tissue)
◦ Frenulectomy or frenulopasty
◦ Excision of hyperplastic tissue or pericoronal gingiva
◦ Surgical reduction of osseous or fibrous tuberosity
◦ Intravenous conscious sedation/analgesia; when provided in conjunction with oral surgery
(surgical procedures) other than simple extractions
◦ Deep sedation/general anesthesia provided by a dentist in conjunction with oral surgery
(other than simple extractions)
• Prosthodontic services for persons age 16 and older
Services, procedures, and appliances that replace missing natural teeth, including bridges and
partial and complete dentures:
◦ Complete and partial dentures
◦ Pontics
◦ Fixed partial denture retainers – inlays/onlays (inlays/onlays placed as abutments, i.e., to retain
or support fixed partial dentures)
◦ Fixed partial denture retainers – crowns (crowns placed as abutments, i.e., to retain or support
fixed partial dentures)
◦ Recement fixed partial denture (1 per lifetime)
◦ Cast or prefabricated post and core; core build-up
◦ Fixed partial denture (bridge) repair
September 2020 SMM | Hospitality Plan Unit 185 Page 15 of 22September 2020
Dental Benefits (continued)
What’s covered under the Delta Dental PPO? (continued)
• Prosthodontic maintenance
Repairs and relines to prosthetic appliances:
◦ Adjustments to complete and partial dentures (2 per year)
◦ Repairs to complete and partial dentures (1 every 2 years)
◦ Replace missing or broken teeth
◦ Add tooth or clasp to existing partial denture (1 per lifetime)
◦ Replace all teeth and acrylic on cast metal framework (1 per lifetime)
◦ Denture rebase (1 every 2 years)
◦ Denture reline (1 every 2 years)
• Orthodontic services
Treatment necessary for proper alignment of teeth:
◦ Orthodontic workup (including x-rays, diagnostic tests, casts and treatment, and the first
month of active treatment, including all active treatment and retention appliance)
◦ Continued active treatment after the 1st month
◦ Fixed or removable appliances (1 appliance per person for tooth
guidance or to control harmful habits)
• Implants
1 every 5-years for a patient age 16 and older
Enhanced Benefits Program (Delta Dental PPO)
You have an Enhanced Benefit Program that provides additional benefits, such as extra cleanings and
more for individuals who have specific health conditions.
You’re eligible for the Enhanced Benefits Program if you:
• Have periodontal (gum) disease
• Have diabetes
• Are pregnant
• Have high-risk cardiac conditions
• Have kidney failure or are undergoing dialysis
• Are undergoing cancer-related chemotherapy and/or radiation
• Have suppressed immune systems due to HIV positive status, organ transplant, and/or stem cell
(bone marrow) transplant
If one of these conditions applies to you, contact Delta Dental of Illinois at 800-323-1743 to sign up.
September 2020 SMM | Hospitality Plan Unit 185 Page 16 of 22September 2020 Dental Benefits (continued) What’s not covered under the Delta Dental PPO? Covered Expenses will not include and Plan benefits will not be provided for any charges incurred or resulting from the following: • Pulp vitality tests billed in conjunction with any service except for an emergency exam or palliative treatment. • Recementation of space maintainers within six months of initial placement. • Fillings are not a covered benefit when crowns are allowed for the same teeth. • Replacement of any existing cast restoration (crowns, onlays, ceramic restorations) with any type of cast restoration within 5 years following initial placement of existing restoration. • Replacement of a stainless steel crown with any type of cast restoration by the same office within 2 years following initial placement. • A cast restoration is a covered benefit only in the presence of radiographic evidence of decay or missing tooth structure. Restorations placed for any other purpose, including, but not limited to, cosmetics, abrasion, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformations of teeth, or the anticipation of future fractures. • When there is radiographic evidence of sufficient vertical height (more than three millimeters above the crestal bone) on a tooth to support a cast restoration, a crown build-up. • Recementing of inlays, onlays, partial coverage restorations, cast and prefabricated posts and cores and crowns by the same office within 6 months of the initial placement. • Additional procedures to construct a new crown under the existing partial denture framework within six months following initial placement. • Sedative filling is requested or placed on the same date as a permanent filling. • Retreatment of the same tooth within 2 years when a benefit has been issued for endodontic services. • Endodontic procedures performed in conjunction with complete removable prosthodontic appliances. • Guided tissue regeneration billed in conjunction with implantology, ridge augmentation/sinus lift, extractions or periradicular surgery/ apicoectomy. • Crown lengthening or gingivoplasty, if not performed at least four weeks prior to crown preparation. • Bone replacement grafts performed in conjunction with extractions or implants. • Periodontal splinting to restore occlusion. • Replacement of any existing prosthodontic appliance (cast restorations, fixed partial dentures, removable partial dentures, complete denture) with any prosthodontic appliance within 5 years following initial placement of existing appliance. • A fixed partial denture and a removable partial denture when requested or placed in the same arch. • Reline or rebase of an existing appliance within 6 months following initial placement. • Fixed or removable prosthodontics for a patient under age 16. • Tissue conditioning. September 2020 SMM | Hospitality Plan Unit 185 Page 17 of 22
September 2020 Dental Benefits (continued) What’s not covered under the Delta Dental PPO? (continued) Covered Expenses will not include and Plan benefits will not be provided for any charges incurred or resulting from the following: • A pontic when the edentulous (toothless) space between teeth is less than 50% of the size of the missing tooth. • Mobilization of an erupted or malpositioned tooth to aid eruption or placement of a device to facilitate eruption of an impacted tooth performed in conjunction with other oral surgery. • Services, supplies, or treatment provided more frequently than stated as a Covered Expense. • Any treatment, services or supplies as set forth in the Section titled “General Plan Exclusions and Limitations.” • Services compensable under Worker’s Compensation or Employer’s Liability laws. • Services provided or paid for by any governmental agency or under any governmental program or law, except as to charges which the person is legally obligated to pay. This exception extends to any benefits provided under the U.S. Social Security Act and its Amendments. • Services performed to correct developmental malformation including, but not limited to, cleft palate, mandibular prognathism, enamel hypoplasia, fluorosis and congenitally missing teeth. This exclusion does not apply to newborn infants. • Services performed for purely cosmetic purposes, including, but not limited to, tooth-colored veneers, bonding, porcelain restorations and microabrasion. Orthodontic care benefits shall fall within this exclusion unless such benefits are provided by endorsement. • Charges for services completed prior to the date the person became covered under this program. • Services for anesthetists or anesthesiologists. • Temporary procedures. • Any procedure requested or performed on a tooth when radiographs indicate that less than 40% of the root is supported by bone. • Services performed on non-functional teeth (second or third molar without an opposing tooth). • Services performed on deciduous (primary) teeth near exfoliation. • Drugs or the administration of drugs, except for general anesthesia and intravenous conscious sedation. • Procedures deemed experimental or investigational by the American Dental Association, for which there is no procedure code, or which are inconsistent with Current Dental Terminology coding and nomenclature. • Services with respect to any disturbance of the temporomandibular joint (jaw joint). • Procedures that Delta Dental of Illinois considers to be included in the fees for other procedures. For such procedures, a separate payment will not be made by this group dental plan. A Dentist in Delta Dental of Illinois’ PPO network or Delta Dental of Illinois’ Premier network may not bill the patient for such procedures. • The completion of claim forms and submission of required information, not otherwise covered, for determination of benefits. September 2020 SMM | Hospitality Plan Unit 185 Page 18 of 22
September 2020
Dental Benefits (continued)
What’s not covered under the Delta Dental PPO? (continued)
Covered Expenses will not include and Plan benefits will not be provided for any charges incurred or
resulting from the following:
• Infection control procedures and fees associated with compliance with Occupational Safety and Health
Administration (OSHA) requirements.
• Broken appointments.
• Services and supplies for any illness or injury occurring on or after the covered individual’s effective date
of coverage as a result of war or an act of war.
• Services for, or in connection with, an intentional self-inflicted injury or illness while sane or insane,
except when due to domestic violence or a medical (including both physical and mental)
health condition.
• Services and supplies received from either a covered individual’s or covered individual’s spouse’s relative,
any individual who ordinarily resides in the covered individual’s home or any such similar person.
• Charges for services for inpatient/outpatient hospitalization.
• Services or supplies for oral hygiene or plaque control programs.
Predetermination of dental benefits
If your Dentist recommends dental work that is estimated to cost $250 or more, you can ask
Delta Dental of Illinois to help you determine how much the Plan will pay at:
Delta Dental of Illinois
P.O. Box 5402
Lisle, Illinois 60532
This is a voluntary program, but contacting Delta Dental before you have complex or expensive dental work
will help you and your dentist understand what the Plan will pay for your proposed care. By contacting
Delta Dental in advance, you will have a better idea of what your share of the costs will be so you don’t get
surprise bills.
If you take advantage of this program, Delta Dental will review your dentist’s records and provide you and
your dentist with an estimate of what you must pay, and what the Plan will pay. Predetermination of benefits
doesn’t guarantee what benefits the Plan will pay or that any benefits will be paid for dental treatment or
services provided. As always, any treatment decisions are between you and your dentist. All plan rules will
apply to any dental claims you file.
Dental benefits after Eligibility ends
If coverage ends for reasons other than termination of the Plan, benefits will only be determined for
Allowable Charges incurred for Covered Expenses furnished before coverage ends. However, if coverage
ends after covered treatment for crowns, jackets, bridges, complete dentures, or partial dentures begins,
benefits for the completion of such treatment will be paid, provided the treatment is completed within
60 days of the date coverage ends. If coverage ends because the Plan terminates, in whole or in part, no
benefits will be available for claims submitted after coverage ends.
September 2020 SMM | Hospitality Plan Unit 185 Page 19 of 22September 2020
Dental Benefits (continued)
Alternate treatment limitation
In the event that the Delta Dental of Illinois determines that an optional, but less costly, course of treatment
exists that will achieve, or would have achieved, the same result as a more expensive course of treatment,
Plan benefits will only be provided up to an amount determined by the less costly course of treatment,
provided that such optional treatment as determined by Delta Dental of Illinois is:
• Commonly used in the treatment of the condition in question.
• Recognized by the dental profession to be appropriate in accordance with the standards of accepted
dental practice.
Filing a dental claim under the Delta Dental PPO
Generally, you do not need to file a claim for dental care. Delta Dental of Illinois providers will file the claim
on your behalf. If you use a non-network dentist, the dentist may file a claim for you, or you may have to pay
the claim yourself and then file a claim with Delta Dental of Illinois.
You can get a claim form from UNITE HERE HEALTH by calling 844-427-8501 or visiting the Hospitality Plan
website at www.uhh.org/hospitality. You will need to provide all information Delta Dental of Illinois needs
to process the claim. Dental claims must be filed no later than 18 months after the date of service. Only
claims that are filed in a timely manner will be considered for payment.
Coordination of Benefits (COB)
For the dental benefits, coordination of benefits will be according to the rules of Delta Dental of Illinois.
September 2020 SMM | Hospitality Plan Unit 185 Page 20 of 22September 2020
Dental Benefits (continued)
Filing a dental appeal under the Delta Dental PPO
If you have questions about your claim, please contact Delta Dental of Illinois at 800-323-1743.
Because most questions about benefits can be answered informally, we encourage you first to try resolving
any problem by talking with us. Of course, you have the right to file an appeal requesting that we formally
review our claim decision, without first making an informal inquiry.
To file an appeal:
• You must send a written request within 12 months from the date you receive your EOB to:
Appeals Subcommittee
UNITE HERE HEALTH
711 Commons Drive
Aurora, IL 60504
• If you have any additional documents, records or other information in support of your appeal, or if you
want to submit written comments, you should include them with your written request.
• Be sure to include the patient name, member name, and the member identification number on
all documents.
• UNITE HERE HEALTH will provide a final written decision on your appeal within 60 days.
• Only after receiving a final written decision from UNITE HERE HEALTH do you have the right to file a
lawsuit against the Plan and/or to request review by an external independent review organization (IRO).
• Any lawsuit must be commenced no more than 12 months after the date of the appeal denial letter.
• If you fail to commence your lawsuit within this 12-month timeframe, you will permanently and
irrevocably lose your right to challenge the denial in court or in any other manner or forum.
• This 12-month rule applies to you and to your beneficiaries and any other person or entity making a
claim on your behalf.
September 2020 SMM | Hospitality Plan Unit 185 Page 21 of 22September 2020
Vision Benefits
Corrections to the Vision benefits
The following corrections are made to the vision benefits section of your SPD:
• Services covered once every 12 months
• If you use a network provider, polycarbonate lenses are covered in full for children through the
end of the month in which they turn 26.
• The following exclusions apply:
◦ Refitting of contact lenses after the initial 90-day fitting period.
◦ Services associated with corneal refractive therapy (CRT) or orthokeratology.
• Low vision benefits:
◦ VSP will cover a maximum of two low vision tests within a 2-year period
(network and non-network combined).
◦ If you get low vision exams from a non-network provider, VSP will pay up to $125 per exam.
• If you use a non-network provider, a $25 copay for frames and a $25 copay for lenses will apply.
• Medically necessary contact lenses.
VSP network provider $0 copay
Non-network providers $0 copay, Plan pays up to $210
• Filing a claim or an appeal with VSP.
◦ Do not send claims or requests for appeal to the Rancho Cordova address shown in your SPD.
Contact VSP at 800-877-7195 when you have questions about filing a claim or requesting an appeal.
◦ If you need to file a claim or an appeal for your VSP vision benefits send the information to:
VSP
P.O. Box 385018
Birmingham, AL 35238-5018
September 2020 SMM | Hospitality Plan Unit 185 Page 22 of 22Septiembre de 2020
SummarydeofModificaciones
Resumen Material Modification
a los Materiales (SMM)
Este es un Resumen de Modificaciones a los Materiales (SMM por sus siglas en inglés). Este documento explica algunos
de los cambios y adiciones que el Consejo Administrativo de UNITE HERE HEALTH (UHH) le ha hecho a sus beneficios.
Estas actualizaciones afectan la información en su Descripción Resumida del Plan (SPD).
Por favor lea esta información detenidamente para que comprenda sus beneficios. Asegúrese de mantener esto con su
libro SPD. Si tiene alguna pregunta acerca de sus beneficios, favor de comunicarse con la Oficina de Servicios al Cliente
del Hospitality Plan al 855-405-3863.
Para protegerlo(a) a usted y a sus dependientes durante la pandemia del coronavirus (COVID-19), los
Fideicomisarios han aprobado cambios temporales en sus beneficios y elegibilidad. Se le notificará cuando estos
beneficios especiales temporales terminen. Este SMM proporciona actualizaciones a los programas que el Fondo
anunció previamente. Debido a la pandemia, usted tiene más tiempo por lo general para hacer ciertas cosas,
como presentar o apelar un reclamo, inscribir a su nuevo dependiente o elegir COBRA y realizar los autopagos de
COBRA. Llámenos para más información.
Los Fideicomisarios también han aprobado otros cambios en sus beneficios (no relacionados con COVID-19),
también descritos en este SMM. Los cambios descritos en este SMM también afectan su Resumen de Beneficios y
Cobertura (SBC, por sus siglas en inglés). Recuerde, siempre puede obtener una copia de su SBC llamando
al Fondo.
¡Su fondo le está cuidando!
A partir del 9 de marzo de 2020, y hasta el final de la emergencia nacional de COVID-19 según
sea declarado por el Departamento de Salud y Servicios Humanos, usted no pagará ningún costo
compartido (copagos, deducibles, o coseguros) por las pruebas médicamente apropiadas o el
tratamiento médicamente necesario para el coronavirus (COVID-19).
Usted no paga costos compartidos por ninguna prueba médicamente apropiada para COVID-19, realizada dentro
de la red o fuera de la red, que haya ordenado un proveedor de cuidado médico. (“Prueba” incluye ambas pruebas
para determinar si actualmente tiene el virus o si tiene anticuerpos contra el virus.) Además, si el objetivo principal
es hacerse la prueba, usted no pagará ningún costo compartido por los artículos y servicios relacionados con la
prueba, incluyendo, por ejemplo, consultas en persona o por telesalud, visitas a centros de cuidados urgentes y salas
de emergencias. Sin embargo, su costo compartido normal se aplica a consultas, artículos y servicios (que no sean
la prueba COVID-19), si el propósito principal de su visita no es obtener o determinar si necesita hacerse una prueba
COVID-19.
Usted tampoco pagará ningún costo compartido por el tratamiento médicamente necesario de COVID-19.
Todas las demás reglas del Plan siguen vigentes, incluyendo las que no están cubiertas. Recuerde, el Fondo no pagará
montos superiores al cargo permitido – si usted utiliza un proveedor que no está dentro de la red, es posible que deba
pagar esos montos aunque no tenga que pagar su costo compartido.
SMM de septiembre de 2020 | Hospitality Plan Unit 185 Página 1 de 22Septiembre de 2020
¡Su fondo le está cuidando! (continúa)
A partir del 19 de marzo de 2020, usted no pagará nada de su bolsillo por consultas de
telesalud dentro de la red.
Muchos proveedores de cuidado médico están exhortando a los pacientes a no salir de su casa y, en cambio,
llamar o programar una cita por video. Si su proveedor ofrece consultas por teléfono o video (telesalud), el
Fondo cubrirá esas consultas. Esto significa que si usted usa un proveedor de la red, no pagará nada de su bolsillo
($0 de copago) por la consulta de telesalud (siempre que el Fondo hubiera cubierto el mismo servicio a través de
una consulta en persona). Sin embargo, si usted utiliza un proveedor fuera de la red para consultas de telesalud, se
aplicarán todos los beneficios fuera de la red, el costo compartido y otras reglas.
A partir del 19 de marzo de 2020, usted no pagará nada de su bolsillo por las consultas de
telesalud de Teladoc.
El Fondo está omitiendo temporalmente el copago de $15 por todas las consultas por video o por teléfono con un
profesional de la salud de Teladoc. Esto significa que usted no tendrá que pagar los copagos mencionados en la
página 3 de este SMM por los servicios de Teladoc.
¡No olvide usar la farmacia de pedidos por correo para sus medicamentos de largo plazo! ¿Por qué?
• Puede ahorrar dinero por lo general.
• Se le enviarán los medicamentos directamente a usted, y no tendrá que salir de casa.
Llame a HospitalityRx al 844-813-3860 si necesita ayuda para obtener sus medicamentos recetados.
SMM de septiembre de 2020 | Hospitality Plan Unit 185 Página 2 de 22Septiembre de 2020
Beneficios Médicos
Prueba de Mamografía
A partir del 1 de enero de 2020, bajo Cuidados de Salud Preventivos, cuando usted acuda a un proveedor den-
tro de la red se le puede hacer más temprano una mamografía de rutina ¡sin ningún copago!
• Una cada año de calendario para todas las mujeres de 35 años o mayores
• Una cada año de calendario para las mujeres menores de 35 años de edad que tienen un alto riesgo de
desarrollar cáncer de mama
Prueba de Cáncer Cervical
A partir del 1 de enero de 2020, bajo Cuidados de Salud Preventivos, cuando usted acuda a un proveedor
dentro de la red, sus pruebas preventivas de cáncer cervical (Papanicolaou) y pruebas para detectar el VPH se
cubren anualmente, a todas las edades, sin ningún copago.
¡Nuevo proveedor de telemedicina!
A partir del 1 de enero de 2020, Teladoc brindará los servicios de telemedicina en lugar de Doctor on Demand.
El copago seguirá siendo $15.
Teladoc
1-800-835-2362
www.teladoc.com
Puede usar computadoras o dispositivos móviles (teléfonos inteligentes, tabletas) para tener consultas por
teléfono o video con un doctor acreditado por el consejo médico. Esto significa que usted puede ver a un
médico aunque no pueda ir a su consultorio.
Algunos motivos para usar Teladoc:
• Dolor de garganta • Problemas dermatológicos (de la piel)
• Fiebre y gripe • (Cargue las imágenes de su problema de la piel y reciba un plan de
• Problemas de sinusitis y alergias tratamiento personalizado dentro de los siguientes 2 días.)
• Vómito y diarrea • Atención pediátrica
• Obtener un medicamento recetado • Consultas de salud conductual
Cómo usar Teladoc:
• Vaya a teladoc.com
• Establezca su cuenta y siga las instrucciones
• Consulte con médicos por video
SMM de septiembre de 2020 | Hospitality Plan Unit 185 Página 3 de 22Septiembre de 2020
Beneficios de Vida y de Muerte Accidental y Desmembramiento
(AD&D, por sus siglas en inglés)
Cambio de nombre del vendedor del Seguro de Vida y Muerte Accidental y Desmembramiento
(AD&D, por sus siglas en inglés)
A partir del 1 de enero de 2020, el nombre de Dearborn National ha cambiado. Ahora se llama Blue Cross Blue Shield
of Illinois. Es posible que todavía vea el nombre Dearborn National en ciertos formularios, etc.
Beneficios Dentales
¡Nuevo proveedor de servicios dentales!
A partir del 1 de enero de 2020, hay un nuevo proveedor de servicios dentales. Delta Dental of Illinois proveerá sus
beneficios dentales en lugar de Cigna, tanto para el DHMO como para el PPO.
Delta Dental of Illinois Partners with DeltaCare DHMO
1-800-422-4234
www.deltadentalins.com/deltacare
Delta Dental of Illinois (Delta Dental PPO)
1-800-323-1743
www.deltadentalil.com
DeltaCare DHMO
UNITE HERE HEALTH ha establecido un contrato con Delta Dental of Illinois para que le brinde a usted y a sus
dependientes beneficios dentales, si usted elige esta opción de beneficios. Esta parte del SMM resume sus beneficios
dentales. Se le dará a usted un documento con detalles que también enumera todos los otros tipos de dependientes
que usted puede inscribir en la cobertura dental, además de los dependientes listados en su Descripción Resumida
del Plan (SPD). Las normas acerca de quién es su dependiente de acuerdo a los beneficios dentales de Delta DHMO
solamente se aplican a dichos beneficios dentales del DHMO, y no aplican con respecto a ningún otro beneficio que
se ofrezca de acuerdo al Plan. Llame a UNITE HERE HEALTH al 833-637-3519 si necesita ayuda para comprender
cuáles dependientes son elegibles para tener la cobertura de Delta Dental, ya que UNITE HERE HEALTH toma todas
las decisiones acerca de elegibilidad. Si llegara a existir una contradicción entre el SPD y los documentos de Delta,
los cuales contienen normas específicas para cada estado acerca de los beneficios y costos compartidos, regirán
los términos de los documentos de Delta. Si tiene alguna pregunta acerca de los beneficios dentales, por favor
comuníquese con Delta Dental of Illinois.
Delta Dental of Illinois Partners with DeltaCare DHMO
800-422-4234
www.deltadentalins.com/deltacare
SMM de septiembre de 2020 | Hospitality Plan Unit 185 Página 4 de 22Septiembre de 2020
Beneficios Dentales (continuación)
DeltaCare DHMO (continuación)
Los beneficios solamente son pagaderos su usted acude al dentista de DeltaCare asignado a usted. En la mayoría
de los estados, se requiere que usted tenga un dentista asignado. Pero algunos estados no requieren un dentista
asignado. Por ejemplo, si usted vive en Mississippi, usted no tendrá un dentista asignado. En esos estados, usted
puede recibir cuidados dentales de cualquier dentista de DeltaCare. Vea la sección “Su dentista primario” en la
página 6 para obtener más información.
Su copago depende de la clase de servicio dental que usted reciba. La tabla que aparece a continuación muestra los
copagos de algunos de los procedimientos dentales más comunes.
DeltaCare DHMO
Característica del Beneficio Lo Que Paga Usted
Deducible para el año de calendario Nada
Beneficio máximo por persona No hay máximo. No hay ningún límite en los beneficios
que se pagan por su cuidado dental cada año.
Examen oral No hay copago
La mayoría de las radiografías No hay copago
Limpieza normal periódica para adulto o profilaxis para No hay copago
menores (1 en cada periodo de 6 meses)
Aplicación tópica de flúor para menores hasta la Copago de $5 por diente
edad de 19 años (1 en cada periodo de 6 meses)
Sellador para menores hasta los 16 años de edad Copago de $5 por diente
Raspado y alisado radicular de terapia No hay copago
periodontal (total de 4 cuadrantes por año)
Mantenimiento periodontal (1 en cada periodo de 6 meses) No hay copago
Obturaciones con amalgama No hay copago
Onlays (metálicos) No hay copago
Coronas Copago de $35 - $195
(dependiendo de la clase de corona)
Gingivectomía o Gingivoplastía Copago de $50 - $80
(dependiendo en los dientes por cuadrante)
Recubrimiento pulpar No hay copago
Endodoncia Copago de $45 - $220
(dependiendo de la clase de endodoncia)
Dentadura completa (superior o inferior) cada 5 años Copago de $100 por dentadura
Reemplazo de la base o remodelación de la superficie de la Copago de $0 - $35
base de una dentadura (1 por dentadura, cada año) (dependiendo de la clase de reparación
Extracción de diente impactado Copago de $25 - $90 (dependiendo de la clase de extracción)
Ortodoncia completa para menores hasta los $1,700
19 años de edad (2 años de tratamiento)
Ortodoncia completa para adultos (2 años de tratamiento) $1,900
SMM de septiembre de 2020 | Hospitality Plan Unit 185 Página 5 de 22You can also read
