| Medicare Supplement/Select Dental Plan |
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A dental plan for you Your Blue Cross and Blue Shield of Minnesota Medicare supplement plan provides solid health coverage and peace of mind. As a Blue Cross member, you also have the opportunity to purchase a dental plan designed to complement your Medicare supplement health plan. It’s a wise choice as numerous studies suggest that good oral health is linked to good overall physical health. This dental coverage is available only to members of Blue Cross Medicare supplement plans (such as Senior GoldSM) through an arrangement with Delta Dental of Minnesota. Delta Dental is the state’s largest dental benefits administrator. Coverage you can count on With this dental plan, you’ll receive:
Enrolling in this dental plan is simple. Your application form is enclosed. Just follow the instructions for filling it out and mail it to: Individual Dental Delta Dental of Minnesota Attn.: Enrollment Department P.O. Box 330 Minneapolis, MN 55440-0330 Questions? If you have questions about the dental plan or need help completing the application, contact your Blue Cross agent or call Delta Dental customer service. Delta Dental Customer Service 7 a.m. – 7 p.m. Central Time, Monday through Friday (651) 406-5995 or toll free 1-888-223-2954 TTY: (651) 406-5923 or 1-888-853-7570 |
Additional coverage details Coverage begins following premium payment Your coverage will take effect on the first day of the month following the date Delta Dental receives your application and initial premium. The initial coverage period is for 12 months, regardless of the terms, conditions and coverage period of your medical plan. Delta Dental guarantees not to change your premiums during those 12 months, and you agree to pay premiums on time for those 12 months Your effective dental coverage date may or may not coincide with your medical coverage date. Only dental treatments begun and completed while coverage is in force are eligible for benefits. Enrollment and cancellation Blue Cross Medicare supplement plan members may purchase the dental plan within 60 days of enrolling in a Blue Cross Medicare supplement health plan or between November 15 and December 31 each year. You must be a Minnesota resident at the time of your application. You may cancel the Delta Dental plan within 30 days of enrolling, or at its renewal date, without cancelling your medical plan. However, once dental coverage is cancelled, you cannot re-enroll for two years. Find complete details in the Delta Dental Benefit Plan Summary This brochure is intended to provide a convenient overview of coverage and is not intended to be a complete description. Only those services and supplies specifically listed in the Delta Dental Benefit Plan Summary are covered under the plan, regardless of dental necessity. The Delta Dental Benefit Plan Summary is your source for complete information, including the specific dental treatments that are covered, the frequency with which those treatments are covered, benefit amounts, limitations, exclusions and conditions under which coverage may remain in force. Exclusions and limitations are also available at www.deltadentalmn.org. You will receive the Delta Dental Benefit Plan Summary with your welcome package. If you decide this coverage is not for you, simply notify Delta Dental in writing within 30 days of receiving the Summary. Your premiums will be refunded, minus any paid claims. You will not be eligible to re-enroll for two years. |
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Individual dental plan benefits and rates for Blue Cross Medicare supplement plan members |
| Your coverage* | $100 annual deductible with $1,000 annual coverage maximum |
| Services covered immediately | |
| Diagnostic/preventive – routine exams and cleanings (up to 2 per calendar year) |
100% No deductible for routine checkups |
| Prosthodontic – (denture) repairs and adjustments | 50% |
| Basic restorative – fillings and sealants | 50% |
| Oral surgery – including extractions | 50% |
| Endodontics – root canals | 50% |
| Services covered after a 12-month waiting period | |
| Periodontal care – treatment of gum disease | 50% |
| Major restorative – crowns and cast restorations | 50% |
| Prosthodontics – dentures, partial dentures and bridges | 50% |
* Coverage at non-network dentists is subject to the maximum amount payable (MAP), which is the maximum amount Delta Dental will pay for a given procedure. If you receive care from a non-network dentist who charges more than the MAP, you’ll be responsible for the additional amount. Delta Dental network dentists agree not to charge more than the MAP. |
| Dental plan cost | Monthly | Quarterly | Annual |
| Premium | $35.20 | $105.60 | $422.40 |