Toll Free Phone: 800-999-9789 Toll Free Fax: 888-998-8709 DentalSelect.com Co-Insurance Plans Classic © Copyright Select Benefits Group 2014 Classic TX2014 CI 05/14 Texas ACE USA is the U.S. domestic operating division of ACE Limited. Insurance products and services are provided by the U.S. insurance underwriting companies and not by ACE Limited. This plan of insurance is underwritten by ACE American Insurance Company. Member Maximums Increase Yearly for Groups 10+ Features MaxRewards sm standard benefit example for groups 10+ Customized starting maximums available IF YOUR MaxRewards sm BENEFIT STARTS AT $1,000 $2,000 Year 1 – Original Year 2 – add $100 Year 3 – add $200 Year 4 – add $300 Year 5 – add $400 $1,600 $1,300 $1,100 $1,000 Year 1 Year 2 Year 3 Year 4 Year 5 In this example, the employee starts with a $1,000 max on their effective date and benefits increase over 5 years when they reach the $2,000 Max. How it Works Increases are automatically applied on the employee’s effective date, each year incrementally based on consecutive coverage & the original maximum benefit set by the group until the maximum benefit reaches $2,000. Plan Design Highlights • Customize any plan • Automatic MaxRewards sm for groups 10+ • Self-funded plans available • Dual Option plans available • Implant benefits available • Additional available plan options include: • Preventive only • Preventive & Basic only • Includes contracted non-insured cosmetic discounts • Members can visit any dentist with the greatest out-of-pocket savings advantage available when receiving care from a contracted provider Co-Insurance Plan Options Choose a Plan: • Indemnity - Indemnity with passive PPO • PPO - Uses contracted and non-contracted providers Provider Panel Options: • Gold (PPO Plans Only) • Platinum Preventive Cleanings (2 per year), exams, fluoride and x-rays 100% or customize Basic Fillings and oral surgery 80% or customize Major Crowns, bridges, dentures, periodontics & endodontics 50% or customize Deductible Per member; effective date year Applies to all basic and major services $50/$150 or customize Maximum Benefit Per member; effective date year Applies to preventive, basic and major services $1,000 or customize Automatic MaxRewards sm for groups 10+ Orthodontics Children & Adults - No waiting periods Non-insured coverage 20% Discount (Medically necessary only also available - 24 Month Waiting Period) The benefits illustrated are in summary form only. They should not be construed as complete in and of themselves. They are only for comparison and in the case of discrepancy, please refer to the plan certificate booklet for a complete description of benefits, limitations and exclusions. Orthodontic Benefit Option Waiting Periods May Apply 50% Children 18 & under $1,000* Lifetime Maximum *Additional maximums available Orthodontic Minimum 10+ Enrolled Underwritten by ACE American Insurance Company • Rated A++ (Superior) by A.M. Best and AA- (Very Strong) by S&P • These ratings are an indication of the company’s financial strength and ability to meet obligations to its insureds • Physical presence in 53 countries • More than 15,000 employees serving the insurance needs of commercial and individual customers in more than 170 countries Visit us at DentalSelect.com Our Plans Include the Federally-Mandated Pediatric Dental Essential Health Benefit This plan is not QHP-certified
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Toll Free Phone: 800-999-9789 Toll Free Fax: 888-998-8709 DentalSelect.com
Co-Insurance PlansClassic
© Copyright Select Benefits Group 2014Classic TX2014 CI 05/14
TexasACE USA is the U.S. domestic operating division of ACE Limited. Insurance products and services are provided by the U.S. insurance underwriting companies and not by ACE Limited. This plan of insurance is underwritten by ACE American Insurance Company.
Member Maximums Increase Yearly for Groups 10+
FeaturesMaxRewardssm standard benefit example for groups 10+ Customized starting maximums available
IF YOUR MaxRewardssm BENEFIT STARTS AT $1,000 $2,000
Year 1 – OriginalYear 2 – add $100Year 3 – add $200Year 4 – add $300Year 5 – add $400
$1,600
$1,300
$1,100
$1,000
Year 1
Year 2
Year 3
Year 4
Year 5
In this example, the employee starts with a $1,000 max on their effective date and benefits increase over 5 years when they reach the $2,000 Max.
How it WorksIncreases are automatically applied on the employee’s effective date, each year incrementally based on consecutive coverage & the original maximum benefit set by the group until the maximum benefit reaches $2,000.
Plan Design Highlights• Customize any plan• Automatic MaxRewardssm for groups 10+• Self-funded plans available• Dual Option plans available• Implant benefits available• Additional available plan options include:
• Preventive only• Preventive & Basic only
• Includes contracted non-insured cosmetic discounts• Members can visit any dentist with the greatest
out-of-pocket savings advantage available when receiving care from a contracted provider
Co-Insurance Plan Options
Choose a Plan: • Indemnity - Indemnity with
passive PPO • PPO - Uses contracted and
non-contracted providers
Provider Panel Options: • Gold (PPO Plans Only) • Platinum
PreventiveCleanings (2 per year), exams, fluoride and x-rays
100%or customize
BasicFillings and oral surgery
80%or customize
MajorCrowns, bridges, dentures, periodontics & endodontics
50%or customize
DeductiblePer member; effective date yearApplies to all basic and major services
$50/$150or customize
Maximum BenefitPer member; effective date yearApplies to preventive, basic and major services
$1,000or customize
Automatic MaxRewardssm for groups 10+
OrthodonticsChildren & Adults - No waiting periodsNon-insured coverage
20% Discount(Medically necessary only also available - 24 Month Waiting Period)
The benefits illustrated are in summary form only. They should not be construed as complete in and of themselves. They are only for comparison and in the case of discrepancy, please refer to the plan certificate booklet for a complete description of benefits,
limitations and exclusions.
Orthodontic Benefit OptionWaiting Periods May Apply
50%Children 18 & under
$1,000* Lifetime Maximum*Additional maximums available
Orthodontic Minimum 10+ Enrolled
Underwritten by ACE American Insurance Company• Rated A++ (Superior) by A.M. Best and AA- (Very Strong) by S&P
• These ratings are an indication of the company’s financial strength and ability to meet obligations to its insureds
• Physical presence in 53 countries• More than 15,000 employees serving the insurance needs of commercial and
individual customers in more than 170 countries
Visit us at DentalSelect.com
Our Plans Include the Federally-Mandated Pediatric Dental Essential Health Benefit
This plan is not QHP-certified
Toll Free Phone: 800-999-9789 Toll Free Fax: 888-998-8709 DentalSelect.com
Co-Insurance PlansClassic
© Copyright Select Benefits Group 2014Classic TX2014 CI 05/14
TexasACE USA is the U.S. domestic operating division of ACE Limited. Insurance products and services are provided by the U.S. insurance underwriting companies and not by ACE Limited. This plan of insurance is underwritten by ACE American Insurance Company.
Request a customized quote for any plan
Plan Design Highlights• Customize any plan• Automatic MaxRewardssm for groups 10+• Self-funded plans available• Dual Option plans available• Implant benefits available• Additional available plan options include:
• Preventive only• Preventive & Basic only
• Includes contracted non-insured cosmetic discounts• Members can visit any dentist with the greatest
out-of-pocket savings advantage available when receiving care from a contracted provider
Contributory
Specialists: See Specialist Notes*
Waiting Periods: No Waiting Periodsor customize
Underwriting Requirements:
Minimum Enrolled 6
Minimum Participation 75%
Voluntary
Specialists: See Specialist Notes*
Waiting Periods: No Waiting Periods**or customize
Underwriting Requirements:
Minimum Enrolled 2
Minimum Participation2-5 - All Must be Enrolled6+ - Minimum 5 Enrolled
**Voluntary groups which have not previously offered a dental program within the last 12 months will include waiting periods unless otherwise requested and approved.
All Specialist Types Available• Specialists include:
• Pediatric Specialists • Oral Surgeons• Endodontists • Periodontists• Prosthodontists • Orthodontists
*Specialist Notes:Co-Insurance Gold plan services rendered by a Dental Select participating Specialist will pay from the General Dentist contracted fee schedule for both in and out of network services. The member will also receive a 20% discount off the Specialist’s fee. Reasonable and Customary payment is not available.Co-Insurance Platinum plan services rendered by a Dental Select participating Specialist will be paid as follows*:The Plan pays according to either the (a) Reasonable and Customary fees or (b) Contracted General Dentist Fee Schedule. The member will also receive a 20% discount off the Specialist’s fee. The Member is responsible for the difference between the Plan’s payment and the discounted Specialist’s fee.Contracted General Dentists and Specialists: Services rendered by a Connection Dental participating General Dentist or Specialist will be reimbursed according to the Connection Dental fee schedule as payment in full; there is no balance billing.*Final payment structure will be determined per Group based on quote or selected Manual Rate Schedule.
What is a PPO plan?A PPO plan is an insured dental plan designed to take responsibility for providing benefits-related services to covered individuals and for managing plan costs. With Dental Select, mem-bers can visit any dentist they choose but with the greatest out-of-pocket savings advantage available when receiving care from a contracted provider.
What is an Indemnity plan?An indemnity plan is one that reimburses the member or provider at a certain percentage of the charges for services rendered, often after a deductible has been satisfied. Indemnity plans typically place no restrictions on which providers a covered individual may visit for services.
Visit us at DentalSelect.com
Co-Insurance Plan Options
Choose a Plan: • Indemnity - Indemnity with
passive PPO • PPO - Uses contracted and
non-contracted providers
Provider Panel Options: • Gold (PPO Plans Only) • Platinum
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