Delta Dental

[bw94366415]

I enrolled in the Delta Dental DeltaCare plan several months ago and one of the main reasons I enrolled is that they advertised Crowns would cost $395.  I went to a participating dentist and had a exam and received a dental treatment plan.  The cost of the crown was $805.  I asked the dental office to explain the fees and they gave me a breakout of the cost.  I called Dental Dental to discuss the cost and they informed me I had to filea grievance I filed a grievance and the response was that I had to pay the $395 plus $80 for a "build up" and $5 office visit.  I called the dentist office back and they had received a letter from Delta Dental and said they could not do the crown for that small amount of payment and would file there own grievance.  It has now been 6 weeks and no results.  When you call Dental Dental they put you on hold and tell you to leave a message. In the mean time I have called 10 other dentist on the approved list of providers and none of them will preform a crown procedure for the $395 advertised Delta Dental does not pay them any more.

I think this is miss advertising and AARP should take some responsibility for this.  I need to have several crowns done which is going to cost a lot more that $395 each.

[GailL1]

@bw94366415 

Your cost that the DeltaCare plan CS rep is quoting is YOUR part of the cost - paid by the enrollee.

You should have a CERTIFICATE OF COVERAGE booklet or perhaps a linked PDF file with all the codes and the copays listed under each of the different types of services. The heading of the (YOUR PLAN BY STATE) booklet is

DeltaCare® USA
Dental Health Care Plan for AARP® Members and Dependents
Combined Evidence of Coverage and Disclosure Form (EOC)

One thing I noticed in the plan is that YOU must pick a primary dentist or they will assign you one - everything flows from that primary dentist - there is a rather strict procedure for changing this primary professional to ensure eligibility.  Sounds to me like you are calling around rather willy-nilly and that is not how DeltaCare works.  You must go thru your primary care dentist for work OR they have to do the referral and tell why.

As long as you have met ALL of the very detailed eligibility requirements including the network (primary) dentist that you are seeing, his referral, if any, pre-exam, etc. (there is a lot of them - all described in the booklet of EOB)  - the amount which the plan pays the network dentist (or his approved referral) is over and above what you have to pay the dental professional for their services. 

Find your Certificate of coverage booklet and read it ALL in detail.  You are not understanding the plan.

[MicksMom36]

How very condescending of you.

"Honored Social Butterfly". That's laughable. 

[bw94366415]

I have read the Certificate of Coverage and I do understand the plan.  I have a primary dentist that gave me the Treatment plan along with the associated charges for each code that is listed.  Included in their treatment plan are charges that are not listed in the Certificate of Coverage and they should not be billing these charges to the patients, ie: temporary crown and Lab Charges. 

[GailL1]

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@bw94366415 wrote:

I have read the Certificate of Coverage and I do understand the plan.  I have a primary dentist that gave me the Treatment plan along with the associated charges for each code that is listed.  Included in their treatment plan are charges that are not listed in the Certificate of Coverage and they should not be billing these charges to the patients, ie: temporary crown and Lab Charges. 

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Of course, I don't know dentist lingo and the ADA 2020 CDT code book is under lock and key but I bet coverage is there for the temp in the Certificate of Coverage under Restorative Services

According to other plans - https://www.deltadentalins.com/individuals/guidance/delta-dentist-advantage.html 

No expensive and unnecessary ”unbundling.” Delta Dental ensures you’re never charged extra for services that should be included in the cost of treatment. For example, when you receive a crown, a Delta Dental dentist cannot charge you additional fees for tooth preparation, local anesthesia, an impression or a temporary crown.

Same thing for for the lab charge(s) - if it is normally all part of the whole procedure then it is probably bundled by the insurance.

Good luck - I know it is frustrating - just don't jump the gun and go to another dentist without getting approval - that's covered in the Certificate of Coverage.

[MicksMom36]

Delta Dental is a scam. They never should have told you to file a grievance against your doctor. That's a serious thing, and trust me when I say, it is NOT your dentist that is the problem. It's Delta Dental. You need to call your dentis and apologize and cancel your delta policy. Their business is to rip off seniors. Shame on AARP for aligning themselves with Delta. 

They have not paid any claims my dentist has submitted and Delta told my dentist that they will not pay for anything for the first year. I need a crown and had to consult with a oral surgeon for a separate, serious, possible future life-threatening issue. All out of pocket after paying premiums to Delta and reading the policy wherein it states a portion of my claims should be paid! To date, I've paid out of pocket over $700 - and I can't get the crown because I can't pay it.  

Even though my plan is monthly, Delta keeps hitting me up for 2 months of premiums in advance. In response, I have stopped paying them anything and have requested the policy be cancelled immediately. I removed my payment info from the account bedcause I do not trust them. 

Read the reviews about Delta Dental on the Consumer Affairs Delta Dental Reviews 
I wish I had seen this before I sent them a dime and enrolled. 

Lots of the same reports from many people. Stay away from Delta, and start complaining to AARP to alert them to this scam insurance and get them to drop Delta.  

[bw94366415]

The dentist office knows I filed the grievance and has received a copy of their response.   They do not agree with the reply that they cannot bill for several of the codes they want to bill me for.  They have indicated to me they are going to appeal the grievance decision.  As slow as Delta Dental is in responding to calls, I am sure it will be a while before I get a reply.

[GailL1]

@MicksMom36 

I would say that many of them don't understand the plan - especially if it is a AARP DeltaCare plan.

This plan is laden with details - all of which have to be followed because it is a gatekeeper type plan.  Meaning that the primary dentist which one picks from their list or is assigned if one isn't pick is paramount to all your care - they are the "gatekeeper" of your dental care - either they do the work, covered or not by the plan, or they refer to another by approval from the plan.

If a person keeps up with all the details of the plan and uses it exactly as is described in their Explanation of Benefits or Certificate of Coverage - it may or may not be a good plan for them because it depends on what they need and the difficulty in performing all the hoop jumping by the plan.

[MicksMom36]

Let me enlighten you. Doctors are not the gatekeepers - the patient is. To suggest people blindly follow whatever their insurance company says is asking for trouble. You should know better. 

If patients do not question the doctor or the insurance companyies, they will get taken for ride. Often times what is in the policy is not what actually occurs. Come on now. These companies are in the business to make money - period. They do not care about anyone's health. 

It is the ignorant patients (the ones you seem to be addressing) that do not step up and challenge their insurance company and charges.  

Delta is an equal opportunity offender. Documented and reported by many customers. That's not because we don't know how to read - it's because we do not sit back - we hold them accountable and refuse to be ripped off. 

You need to learn the difference.

[GailL1]

@MicksMom36 

When used in relation to health or dental insurance, the term gatekeeper describes the person in charge of a patient's treatment. Anyone who receives health insurance coverage in the form of a managed care plan,  is assigned a gatekeeper or allowed to choose one.

AARP DeltaCare is such a plan - This is the AARP  DeltaCare plan in Georgia - 

https://www.deltadentalins.com/aarp/sites/default/files/2020-02/certificate-of-coverage-ga-dhmo.pdf 

Page 4 reads:

Enrollment Process:

• Choose a Contract Dentist facility from the DeltaCare USA network directory that is most convenient for you. A list of Contract Dentists is available at deltadentalins.com or by calling Customer Care at 877-522-9156.
• Complete the “DeltaCare USA Enrollment Application” and be sure to add your selected Contract Dentist’s name and facility ID number. If you fail to select a Contract Dentist or the Contract Dentist selected becomes unavailable, we will request the selection of another Contract Dentist or will assign you to another Contract Dentist.

Page 6 says

What is the DeltaCare USA Plan?  This Plan provides Benefits through a convenient network of Contract Dentists in the state of Georgia. These Dentists are screened to ensure that our standards of quality, access and safety are maintained. The network is composed of established dental professionals. When you visit your Contract Dentist, you pay only the applicable Copayment for Benefits. There are no deductibles, lifetime maximums or claim forms. You must obtain dental services from or be referred for Specialist Services by your Contract Dentist.

The plan is very detailed as the example Certificate of Coverage indicates.  There is a grievance process as with most insurance plans - even Medicare.  But with this particular plan, you have to have a Contract Dentist to perform the work or refer you to another if needed.

Yes, when you sign up for any type of insurance - health, dental, homeowner, auto - you sign a contract with the insurer for the plan as described - then it is renewable usually annually.

Don't like the terms of the contract - just go somewhere else until you run out of options.

Sure, they are there to make money - they are private insurers.  But the only way they can make money is by offering services at a cost that people like and can afford. 

The more benefits, the more self-referral, the wider the network, if any, the lower the beneficiaries out of pocket cost - the more expensive the premiums

The higher the deductibles / co pays / co insurance, the lower the premiums

The more control which they can exert over your care, like a managed care plan (DeltaCare with a Contract Dentist) the lower the premiums

The less services provided or the fewer network providers, the lower the premiums.

It is NOT about who yells the loudest wins !