NewMexicoRe+reeHealthCareAuthorityDentalPlans

Effec+veDate:January1,2019

DeltaDentalofNewMexico

Reminder-ChooseBetweenTwoPlansBasicPlanCovers:

–  Preven+veServices(suchasevalua+onsandcleanings)–  BasicServices(suchasfillingsorextrac+ons)

DoesNotCover:–  Surgicalperiodon+cs–  Complexoralsurgery–  AnytypeofMajorService,orOrthodon+cs

ComprehensivePlanIncludesthecoverageapplicableundertheBasicPlan,plus:

–  Surgicalperiodon+cs–  Complexoralsurgery–  MajorServices(crowns,dentures,andimplants)–  Orthodon+cs

CHOOSEWISELYTOMEETYOURNEEDS!

RatesEffec+ve1/1/193.9%Increase

BasicPlan:Re+reeOnly: $19.23(+$0.72)

Re+ree+1Dependent: $36.07(+$1.35)

Re+ree+2ormoreDeps: $60.42(+$2.27)

ComprehensivePlan:Re+reeOnly: $42.93(+$1.61)

Re+ree+1Dependent: $81.58(+$3.06)

Re+ree+2ormoreDeps: $131.69(+$4.94)

Ratesareguaranteedfortwo(2)yearsthrough12/31/20.

PPONewMexico–InState DeltaDentalPPO FindaDen+st

“In-Network”providersinNewMexico

2,235pointsofaccess,withmorethan95%ofspecialists

par+cipa+ng

“In-Network”providersoutsideofNewMexico

Na+onally,almost266,000points

ofaccess

Wheneverpossible,use“In-Network”den+sts

Onlineden+stsearchatwww.deltadentalnm.com

Pa+ents will not be billed for any amount over theDelta DentalMaximum Approved Fees. AlwaysreviewyourEOBfor theApprovedFeemaximums. Par+cipa+ngprovidersadhere tohigherbenefitlevelsandimportantmemberprotec+onsapply.Out-of-networkden+stsdonotagreetothesamediscounts,resul+nginhigherout-of-pocketcostsand lowerbenefits. Shouldanout-of-networkproviderbeused, cost increasesmaybe limitedbyselec+ngaDeltaDentalPremier®provider,withover356,000pointsofaccess.

ProviderNetworksOverview-StayIn-Network!

SAVEMONEY,STAYIN-NETWORK!

BenefitsOverview

CalendarYearDeduc+bles•  $50perenrolledperson•  $150aggregateperfamily

•  SameforBasicandComprehensivePlans•  NeverappliestoDiagnos+c&Preven+ve•  DoesnotapplytotheOrthodon+cServicesthatarecoveredundertheComprehensivePlan

CalendarYearAnnualMaximums•  BasicPlan:$1,500perenrolledperson•  ComprehensivePlan:$1,500In-Network/$1,000Out-of-Network

1/1/19BenefitEnhancement!

GoodNews,anExtraCleaningAdded!

Wewillnowprovideuptothree(3)Rou+neCleaningspercalendaryear.ThisappliestoboththeBasicandComprehensiveplanop+ons.

BasicPlanPPONewMexico Out-of-Network

Diagnos+candPreven+veServices–NoDeduc+bleTworou+neandoneproblem-focusedOralEvalua+oneachyear.Threerou+necleanings*eachyear,RadiographicImages,TopicalFluoride,EmergencyTreatment,SpaceMaintainers,Sealants

PlanPays:100% YouPay:0%

PlanPays:25%

YouPay:AnyAmountBalanceBilled

BasicServicesFillings,StainlessSteelCrowns,SimpleExtrac+ons,Non-SurgicalPeriodon+cs,RootCanals,GeneralAnesthesia,andRepairsto:onlays,bridges,crowns,anddentures

PlanPays:80% YouPay:20%PlanPays:25%

YouPay:AnyAmountBalanceBilled

MajorServices NotCoveredYouPay:100%

NotCoveredYouPay:100%

Orthodon+cServices NotCoveredYouPay:100%

NotCoveredYouPay:100%

*Coversrou+necleaningstwiceperyear.Individualswithcertainmedicalcondi+onsmayqualifyfor2addi+onalcleanings.

ComprehensivePlanPPONewMexico Out-of-Network

Diagnos+candPreven+veServices–NoDeduc+bleTworou+neandoneproblem-focusedOralEvalua+oneachyear.Threerou+necleanings*eachyear,RadiographicImages,TopicalFluoride,EmergencyTreatment,SpaceMaintainers,Sealants

PlanPays:100% YouPay:0%PlanPays:75%

YouPay:AnyAmountBalanceBilled

BasicServicesFillings,StainlessSteelCrowns,Extrac+ons,OralSurgery,Periodon+cs(surgicalornon-surgical),RootCanals,GeneralAnesthesia,andRepairsto:onlays,bridges,crowns,anddentures

PlanPays:80% YouPay:20%PlanPays:55%

YouPay:AnyAmountBalanceBilled

MajorServices

Onlays,Crowns,Bridges,Par+alsorCompleteDentures,SpecifiedImplantProcedures PlanPays:50% YouPay:50%

PlanPays:35%YouPay:AnyAmount

BalanceBilled

*Coversrou+necleaningsthreeperyear.Individualswithcertainmedicalcondi+onsmayqualifyfor1addi+onalcleaning.

ComprehensivePlan–OrthoBenefits

Orthodon+cServices(AllAges)NoDeduc+ble

In-Network Out-of-Network

50%Benefitupto$1,000life+memaximum

50%Benefitupto$500life+memaximum

Rou+neCleaningsVersusPeriodontalCleanings

•  MemberswithoutPeriodontalDisease–  3Rou+neCleaningsperCalendarYear

•  MemberswithPeriodontalDisease–  3rou+necleaningsand1periodontalmaintenancecleaningpercalendaryear

OR–  4periodontalmaintenancecleaningspercalendaryear–  Benefitsnottoexceedatotaloffourproceduresinanycalendaryear

SpecifiedMedicalCondi+ons–Addi+onalCleanings

• Memberswithspecifiedmedicalcondi+onsmaybeeligibleforaddi+onalcleanings(upto4totalayear)orfluoridetreatment

– PeoplewithdiabetesANDperiodontal(gum)disease

– WomenwhoarepregnantANDwhohaveperiodontal(gum)disease– Peoplewithcertainheartcondi+onsthatputthemathighormoderateriskforinfec+veendocardi+s,apoten+allydeadlyheartinfec+on

– Peoplewithkidneyfailureorwhoareundergoingdialysis– Peoplewithsuppressedimmunesystemsduetochemotherapyand/orradia+ontreatment,HIVposi+vestatus,organtransplant,and/orstemcell(bonemarrow)transplant

•  Talkwithyourden+stifyouqualifyunderoneofthesemedicalcondi+ons.Theywillsubmittherequireddocumenta+onwiththeclaimsubmission.

Pre-TreatmentEs+mateofBenefits

ASKYOURDENTISTFORAPRE-TREATMENTESTIMATEwhenmorecostlyprocedures

arean+cipated.Knowyourcostsahead!

Pa+entDisclosure–You’reen+tledtoit!

þ Anadvancees+mateofbenefitsbeforedentalcareservicesarereceived.Knowyourout-of-pocketcost.

þ Notrequiredbutstronglyrecommended.þ Nochargeforapre-treatmentes+mate.

DeltaDentalHelpfulTips•  Rememberyounowareabletoreceiveupto3Rou+neCleaningsina

CalendarYear•  Remember,stayIn-NetworkbyseeingacontractedPPONewMexico

provider.Youreceivethehighestlevelofbenefitsandtheleastamountout-of-pocketcost.

•  Needtofindaprovider?Gotowww.deltadentalnm.comorsearchthena+onaldirectoryoutsideofNewMexicoforaDeltaDentalPPOprovider.

•  Registeronlinetoseehowyourclaimswerepaid.•  AlwaysaskiftheproviderisaCONTRACTEDPPONewMexicoprovider,as

thisisspecificallytheNMRe+reeHealthcareAuthority’scontractedplan.Allotherswillbetreatedasout-of-networkproviders.

•  Askaboutyourprocedurebeforeitisdone.Don’tassumeitwillbecoveredjustbecausetheprovidersaysyouneedit.Makesureyouknowyourout-of-pocketcosts!

•  Choosetherightplanforyourneeds!

BenefitInforma+on/Ques+ons?

www.deltadentalnm.com

CustomerService

Phone:505-855-7111Toll-free1-877-395-9420AutomatedVoiceResponseSystem

Getbenefitinforma+on24/7

ExperiencedCustomerServiceRepresenta+ves

AvailableMonday–Friday8:00AM-4:30PM(MST)

Email:customerservice@deltadentalnm.com