Affordable Care Act (ACA) Dental Plans
Information for individuals who are enrolled in an ACA (Affordable Care Act) certified dental plan through the Health Insurance Marketplace
See Delta Dental of Illinois Affordable Care Act (ACA) Dental Plan Benefit Highlights.
Out-of-Network Liability and Balance Billing
Delta Dental of Illinois Individual and Family Basic, Preferred, Kids Basic and Kids Preferred Plans
These plans are Delta Dental PPO plans only. The policyholder/member must choose a Delta Dental PPO dentist to receive coverage for dental care. There are no benefits with Delta Dental Premier or non-network dentists.
If the policyholder/member visits a dentist that does not participate in the Delta Dental PPO network, the policyholder/member may be liable for all charges incurred for dental services received, except for emergency care.
Click here to find a dentist. Be sure to select a Delta Dental PPO dentist. The policy/holder must choose a Delta Dental PPO dentist to receive coverage for dental care.
Delta Dental of Illinois Individual and Family Preventive Plan
This plan is a Delta Dental PPO Plus Delta Dental Premier plan. The policyholder/member can choose any dentist – Delta Dental PPO, Delta Dental Premier or non-network dentist.
While the policyholder/member can choose any dentist, they will save the most by using a Delta Dental network dentist, especially a Delta Dental PPO dentist.
Why? Delta Dental network dentists agree to accept our allowed fees as payment in full for dental services. This means Delta Dental network dentists cannot bill the policyholder/member the difference between what they charge for a dental service and what Delta Dental of Illinois allows. This requirement for network dentists is how Delta Dental of Illinois protect our policyholders/members from unexpected charges. Non-network dentists can bill the policyholder/member for charges above our allowed fees.
Click here to find a dentist. The policyholder/member can choose any dentist – Delta Dental PPO, Delta Dental Premier or non-network dentist.
Submitting Claims
If the policyholder/member visits a Delta Dental network dentist, they will submit a claim for the policyholder/member. If the policyholder/member visits a non-network dentist, the policyholder/member may have to submit their own claim. If needed, download a claim form, complete and mail to:
DDIL-Individual
P.O. Box 103
Stevens Point, WI 54421
PAYOR ID: WDENC
Claims must be submitted within one year after dental treatment. For more information or assistance with submitting a dental claim, please call our customer service department at 833-247-4746, Monday through Friday, 8 a.m. - 5 p.m. (Central Time).
Please note the following:
Delta Dental of Illinois Individual and Family Preventive Plan
This plan is a Delta Dental PPO Plus Delta Dental Premier plan. The policyholder/member can choose any dentist – Delta Dental PPO, Delta Dental Premier or non-network dentist.
Delta Dental of Illinois Individual and Family Basic, Preferred, Kids Basic and Kids Preferred Plans
These plans are Delta Dental PPO plans only. The policy/holder must choose a Delta Dental PPO dentist to receive coverage for dental care. There are no benefits with Delta Dental Premier or non-network dentists.
If the policyholder/member visits a dentist that does not participate in the Delta Dental PPO network, the policyholder/member may be liable for all charges incurred for dental services received, except for emergency care.
If the policyholder/member receives treatment for an emergency condition from a non-network dentist, the policyholder/member should file a claim only if that dentist has not filed one on their behalf. The policyholder/member should file a claim only after the procedure is completely finished. The policyholder/member should not file a claim for payment before a procedure is completed. If the policyholder/member receives treatment for an emergency condition from a non-network dentist, Delta Dental of Illinois will pay the policyholder/member directly, unless the policyholder/member assign the payment to their dentist.
Paying Premium
The policyholder/member is required to pay their premium by each premium payment due date. If the policyholder/member does not do so, their coverage could be terminated. While each premium is due by the due date, there is a grace period for each premium payment. Please see below for grace period details.
Grace Periods for Premium Payment and Policies for Pending Claims During Grace Periods
There are two grace periods – one for policyholder/members who do not receive advance payments of the premium tax credits and one for policy holder/members who do receive advance payments of the premium tax credits. If the premium payment is not received by the end of the respective grace period, coverage will terminate as follows:
- If the policyholder/member does not receive advance payments of premium tax credits for coverage in the Illinois Health Insurance Marketplace and fails to pay the required premium within a 31-day grace period, their coverage will terminate retroactively back to the last date premiums were paid. The policyholder/member will be responsible to pay for any claims submitted during the grace period.
- During the 31-day grace period, any claims submitted for the policyholder/member will be pended. When a claim is pended, that means no payment will be made to the dentist until their delinquent premium is paid in full. If the policyholder/member pay their full outstanding premium before the end of the grace period, all claims for covered services the policyholder/member received during the grace period that are submitted properly will be paid.
- If the policyholder/member receives advance payments of the premium tax credit and has paid at least one full month's premium, the policyholder/member is entitled to a grace period of three consecutive months. During the grace period, all appropriate claims for services rendered during the first month of the grace period will be paid. Claims for services rendered may be pended in the second and third months of the grace period if payment is not received.
- If the policyholder/member pays their full outstanding premium before the end of the three-month grace period, all claims for covered services that are submitted properly for the second and third months of the grace period will be paid.
- If the policyholder/member does not pay all of their outstanding premium by the end of the three-month grace period, their coverage will terminate. If their coverage terminates, any pended claims submitted during the second and third months of the grace period will not be paid to their dentist and their dentist can bill the policyholder/member for the amount owed.
Claims Processing Notification and Benefit Determination
Delta Dental PPO and Delta Dental Premier network dentists are paid directly. The policyholder/member will receive an Explanation of Benefits Statement that describes the services their dentist submitted and the benefits that their dental program covers. The treating dentist will receive an Explanation of Payment along with the payment. The policyholder/member will receive an Explanation of Benefits (EOB) statement. (Information detailed on an EOB is below.)
The policyholder/member can elect to receive Explanation of Benefits (EOB) statements electronically through the member portal. If electronic EOB statements are not requested, EOBs are mailed unless their payment responsibility is $0. EOBs where the policyholder/member’s payment responsibility is $0 are only available through the member portal.
If the policyholder/member’s claim is denied in whole or in part, the policyholder/member will receive written notification within 30 days after Delta Dental of Illinois receives a completed claim form. In certain cases, an extension beyond the 30 days may be required.
If the policyholder/member is covered by the Delta Dental of Illinois Individual and Family Preventive plan and uses a non-network dentist or the policyholder/member are covered by a Delta Dental of Illinois Individual and Family Basic, Preferred, Kids Basic and Kids Preferred plan and receives treatment for an emergency condition from a non-network dentist, Delta Dental of Illinois will pay the policyholder/member directly, unless the policyholder/member assigns the payment to their non-network dentist. If the policyholder/member has assigned payment to their non-network dentist, their dentist will be paid directly.
If the policyholder/member does not assign payment to their non-network dentist, the policyholder/member will receive an EOB that describes the services their dentist rendered and the benefits that Delta Dental of Illinois dental benefit plan covers along with the payment to the policyholder/member.
Retroactive Denials
A retroactive denial is the reversal of a previously paid claim, through which the enrollee then becomes responsible for payment.
Delta Dental of Illinois does not retroactively deny claims.
Recouping Overpayments
Recoupment of overpayments is the refund of a premium overpayment by the policyholder as a result of the insurer over-billing the policyholder.
Delta Dental of Illinois does not refund overpayment of premium by the policyholder unless the policy is termed. If the policy is active, Delta Dental of Illinois provides a credit on the policyholder’s account.
Pre-Treatment Estimate Timeframes
A pre-treatment estimate for dental procedures is not required. However, a pre-treatment estimate is recommended for treatment plans exceeding $200. The pre-treatment estimate lets the policyholder/member know in advance whether the requested services are covered under their policy.
Delta Dental of Illinois will typically respond to a request for a pre-treatment estimate for dental services within 72 hours of receipt for urgent cases or 30 days for non-urgent cases.
There are no penalties for not obtaining a pre-treatment estimate.
When the policyholder/member is covered by a dental plan, the policyholder/member receives an Explanation of Benefits (EOB) from their dental carrier after a dentist provides treatment. The EOB is not a bill, but rather an explanation of the procedures that were performed at the appointment and what is covered by the policyholder/member’s specific dental plan.
The EOB includes the portion the policyholder/member’s plan paid and any amount the policyholder/member may owe (such as the deductible, coinsurance or non-covered services). It should also include an update on how much of their annual maximum has been used and the amount the policyholder/member has paid toward their deductible. Delta Dental of Illinois will send the policyholder/member an EOB after a claim is paid.
The policyholder/member can access their EOB any time through the member portal. The policyholder/member can elect to receive Explanation of Benefits (EOB) statements electronically through the member portal. If electronic EOB statements are not requested, EOBs are mailed unless their payment responsibility is $0. EOBs where the policyholder/member’s payment responsibility is $0 are only available through the member portal.
Coordination of Benefits (COB)
Coordination of benefits (COB) is when the policyholder/member and/or their dependents are covered by more than one benefit plan (dual coverage), and the two benefit plans are coordinated so that no more than 100 percent of the total covered expense of any treatment is paid.
Delta Dental of Illinois may coordinate benefits with other dental insurance carriers.