Dental Plan BenefitsAugust, 2012 Administered by

Delta Dental of New Mexico

Delta Dental PPOSM Delta Dental Premier®

Select a Delta Dental PPO dentist to help reduce patient out-of-pocket costs.

Select a Delta Dental Premier dentist if you prefer or if specialty care is needed

and not available in Delta Dental PPO.

Find a Dentist

UNM Hospitals Dental PlanProvider Network Overview – Point-of-Service Plan

One Plan, two network choices! Plan Participants can select any dentist in either the Delta Dental Premier® or

Delta Dental PPOSM network at the time dental services are received.

Over 900 points of access in New Mexico

Over 155,500 dentist locations nationally

Over 236,500 dentist locations nationally

Over 1,270 points of access in New Mexico

Log on to DeltaDentalNM.com to search for a dentist. Pre-selection of a dentist is not required and every member of your family may

visit a different dentist. There is no need to contact Delta Dental to change your dentist; you may

change as often as you like. Whenever possible, use in-network dentists.

Lower out-of-pocket costs, and important member protections apply when services are received in-network!

UNM Hospitals Dental PlanProvider Network Overview – Point-of-Service Plan

The illustration below shows how the reduced Maximum Approved Fees for Delta Dental PPO

can result in significant patient savingsExample assumes Procedure Code 2790(Crown—Full Cast High Noble Metal)

  Delta Dental PPOProvider

Delta Dental Premier Provider

Dentist Submitted Charge

$1,142 $1,142

Delta Dental Maximum Approved Fee (network-specific)

$809 $1,025

Participant Pays (50% Co-payment for Major Services)

$404.50(50% of $809)

$512.50(50% of $1,025)

Savings of

over $100!

UNM Hospitals Dental PlanDental Plan Benefits Overview

Separate Lifetime Maximums apply to Orthodontic Services

Calendar Year Deductibles$50 per enrolled person

$150 aggregate per family

Does not apply to Diagnostic, Preventive, or Orthodontic Services

Calendar Year Maximums

$1,200 per enrolled person per calendar period

Out-of-network dentists may balance bill patients for amounts over Maximum Approved Fees.

Delta Dental PPOSM Delta Dental Premier®

Diagnostic and Preventive Services – No Deductible

Covered Oral Exams & Cleanings (2 per Calendar Year), X-rays, Fluoride Application, Emergency Treatment, Sealants, Space Maintainers, and Diagnostic Casts

Delta DentalPays 100%

YouPay 0%

Delta DentalPays 100%

YouPay 0%

Basic Services

Fillings, Stainless steel crowns, Extractions, Oral Surgery, Root canals, Periodontics (surgical or non-surgical), and General Anesthesia

Delta Dental Pays 80%

YouPay 20%

Delta DentalPays 80%

YouPay 20%

Major Services

Onlays, Crowns, Bridges, Partials or Complete dentures, Specified Implant Procedures

Delta Dental Pays 50%

YouPay 50%

Delta DentalPays 50%

YouPay 50%

UNM Hospitals Dental PlanDental Plan Benefits Overview

Out-of-network dentists may balance bill patients for amounts over Maximum Approved Fees.

UNM Hospitals Dental PlanOrthodontic Benefit Overview

ORTHODONTIC SERVICES (child and adult)No deductible

Delta Dental Pays 50%up to $1,000 lifetime maximum

Enrollees Pay 50% plus balance of cost up to the applicable Delta Dental Maximum Approved Fee

UNM Hospitals Dental PlanPredetermination of Benefits

ASK YOUR DENTIST FOR A PREDETERMINATION OF BENEFITS

when more costly procedures are anticipated.

Patient Disclosure –You’re entitled to it!

An advance estimate of benefits

before dental care services are

received

Not required, but strongly

recommended

No charge for this service.

UNM Hospitals Dental PlanSpecial Eligibility Provisions

UNM Hospitals Special Eligibility Provisions

If you enroll one dependent (spouse/domestic partner/child), all dependents must be enrolled (except children younger than 3 years of age) unless you can provide UNMH HR with proof of other coverage.

Children are covered to age 26 regardless of employment, marital, or student status.

UNM Hospitals Dental PlanInformation Available 24/7!

Subscriber Information Available 24/7!Featured Plan Information Available in the Member Section

View and print: Summary of Benefits Dental Benefit Plan Provisions Provider Directory

Consumer Toolkit Verify eligibility of subscriber and dependents Confirm status of deductibles and plan maximums Review how a specific claim was processed Print a personalized subscriber ID card

Oral Health Links Oral Health Assessment Oral Health and Wellness Portal

DeltaDentalNM.com

UNM Hospitals Dental PlanCustomer Service

Experienced Benefit Representatives No frustrating “menu of options” from

which to choose Talk to a local representative with 45

seconds of calling

Hours of Operation:

•Monday – Friday 8:00am-4:30pm

•Albuquerque: 505-855-7111

•Toll free: 1-877-395-9420

We do dental. Better.

Questions?

UNM Hospitals Rates

COVERAGE TYPEEmployee

COST Full Time

Employee COST Part

Time

Employee $ 0.00 $ 6.10

Employee + 1 $ 17.50 $ 23.60

Employee + 2 or more

$ 33.50 $ 39.60

Per Pay Period (24/Year)