Two great dental programs For 2021 Kaiser Permanente Federal Members You must be enrolled in one of Kaiser Permanente’s medical plans to elect KPIC Dental Insurance Plan or DeltaCare® USA dental coverage We keep you smiling® Kaiser Permanente is pleased to offer Federal employees and eligible Federal retirees and dependents who are currently enrolled or planning to enroll in one of Kaiser Permanente’s medical plans a choice of the dental plans described below. Option 1 is a dental PPO plan underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., and is administered by Delta Dental of California (Delta Dental). Option 2 is a DeltaCare® USA dental HMO program provided by Delta Dental of California and administered by Delta Dental Insurance Company. (These companies are financially responsible for their own products.) These benefits are neither offered nor guaranteed under a contract with the Federal Employees Health Benefit (FEHB) Program, but are made available to all enrollees and family members who become members of Kaiser Permanente. During the annual open enrollment period, you have the opportunity to enroll in one of the two plans. If you are already enrolled, you may change plans during this period. Your coverage under the enrolled plan will become effective on January 1, 2021 and will extend through December 31, 2021, subject to your continued premium payments and enrollment in Kaiser Permanente’s traditional HMO Plan. If you are already enrolled under one of the two dental plans and are not planning on changing your coverage, you do not need to complete the enrollment form. If you are changing plans, you must provide 30‑days advance written notice of termination. If you are covered under Option 1, the notice must be sent to Delta Dental (see page 11 for address). If you are covered under Option 2, the notice must be sent to DeltaCare USA (see page 23 for address). If you are not already enrolled, for questions about KPIC’s Dental Insurance Plan, contact Delta Dental at: 800‑933‑9312 Monday through Friday, 8 a.m. — 4 p.m. Pacific time Your Kaiser Federal plan ID number is #09874 If you are already enrolled in the KPIC Dental Insurance Plan, for more information, contact Delta Dental at: 800‑835‑2244 Monday through Friday, 8 a.m. — 8 p.m. Pacific time Your Kaiser Federal plan ID number is #09874 For questions about DeltaCare USA, contact Delta Dental at: 800‑422‑4234 Monday through Friday 8 a.m. — 8 p.m. Pacific time Your Kaiser Federal plan ID number is #71114 You have two dental plans to choose from: 1 2 KPIC’s Dental PPO Insurance Plan allows you the freedom to DeltaCare USA is a dental HMO program. With DeltaCare see any licensed dentist of your choice. It uses a USA, you select a conveniently located network dentist Table of Allowances that lists the dollar amount KPIC will to provide dental care for you and your family. A list pay for each covered dental service. A copy of the of participating network dentists is enclosed for your review. Table of Allowances is included in this brochure. You must Depending on the service you receive, you pay either a set be enrolled in Kaiser Permanente’s traditional HMO dollar copayment or no copayment at all. With the DeltaCare medical plan to elect this dental coverage. USA program, there are no deductibles and no claim forms. You must be enrolled in Kaiser Permanente’s traditional HMO medical plan to elect this dental coverage. With KPIC’s Dental PPO Insurance Plan . With DeltaCare USA . • You have the freedom to choose any licensed dentist. • You select one of the more than 6,400 network dentists • Each family member may visit a different dentist. statewide. • Table of Allowances lists the specific dollar amount • General dental care for the entire family is provided an payable for each covered dental service. assigned Contract Dentist. Specialty care is coordinated • Your out‑of‑pocket costs will usually be lowest if you through your Contract Dentist. visit a Delta Dental PPOTM Dentist (PPO Dentist). If you • You pay a set or no copayment for covered services. can’t find a PPO Dentist, a Delta Dental Premier® Dentist • Orthodontic services (braces) with a copayment of $1,600 (Premier Dentist) is your next best option. PPO and for children under 19 and $1,800 for covered adults and Premier dentists will not bill you above their Delta Dental dependent adult children. contracted fees for covered services. • There are no claim forms to complete. • Find Delta Dental dentists at deltadentalins.com. • There are no deductibles. • Orthodontic services (braces) are not covered. • There are no annual maximums except for accidental • Claims are handled for you when you visit one of Delta injury. Dental’s approximately 47,100 participating dentist locations in California. • Use your 10‑digit Kaiser Permanente Medical Record Number (MRN) or your social security number as your ID (to use your MRN, include the leading zeros). • There is an annual deductible of $50 per person ($150 maximum per family); the maximum coverage annually is $1,000 per person. • There is no deductible for diagnostic and preventive services. • Some procedures are subject to a waiting period. See KPIC Dental section beginning on page 2 See DeltaCare USA section beginning on page 14 KPIC Dental Insurance Plan Monthly premium* DeltaCare USA Monthly* Quarterly* Self only $35.38 Self only $14.26 $42.77 Self and 1 party $62.71 Self and 1 party $23.87 $71.60 Self and 2 or more $94.26 Self and 2 or more $36.18 $108.53 * Good through December 31 * Good through December 31 These benefits are neither offered nor guaranteed under contract with the FEHB Program. Remember that you are enrolling in your selected dental plan for a minimum of 12 consecutive months. This does not apply if your employment is terminated. Payment for either the KPIC or DeltaCare USA plan may be automatically withdrawn from the checking, savings or credit union account you specify. To review a brochure of the program, visit kp.org/feds. 1 KPIC Dental KPIC Dental PPO Insurance Plan One of your non‑FEHB Dental plan options is a About KPIC’s Dental Insurance Plan dental PPO insurance plan underwritten by KPIC, If you’re concerned about the cost of dental treatment for and administered by Delta Dental of California. you and your family, you should know about KPIC’s dental PPO insurance plan. With a low monthly premium, KPIC’s KPIC’s dental PPO insurance plan uses a Table of group dental insurance plan allows you to budget for Allowances and allows you the freedom your annual dental costs. You can do this because KPIC’s dental PPO insurance plan contains a Table of Allowances to see any licensed dentist of your choice. The listing the specific dollar amount KPIC will pay for each Table of Allowances lists the dollar amount covered dental service. Since you receive in advance the KPIC will pay for each covered dental service. complete Table of Allowances for the plan, you’ll know A copy of the Table of Allowances is shown exactly how much of your treatment will be covered. on pages 6 and 8 of this brochure. Because dental fees do vary by dentist, it may be to your advantage to compare your dentist’s fees prior to making The monthly premiums for calendar year 2021 an appointment. are listed below: Who can join KPIC Dental Insurance Plan Monthly premium* As a Federal employee or a Federal retiree enrolled in one of Kaiser Permanente’s Plans, you and your eligible Self only $35.38 dependents are eligible for coverage under KPIC’s dental Self and 1 Party $62.71 PPO insurance plan. Your eligible dependents include your Self and 2 or more $94.26 lawful spouse and children from birth to age 26, including * Good through December 31, 2021 stepchildren and children placed with you for adoption or foster care. A child 26 years of age or older may continue to These benefits are neither offered nor guaranteed under contract with the FEHB be eligible as a dependent if incapable of self‑support due Program. to a mental or physical disability that commenced prior to age 26, provided that the person is chiefly dependent upon the eligible member, due to a mental or physical disability, Note: This is only a brief description of your and Delta Dental receives notice of the disability. coverage. A certificate of insurance and schedule of coverage setting forth the terms and conditions Free choice of dentists of your coverage will be sent to you after you enroll. You may see any dentist for your covered treatment whether the dentist is a PPO Dentist, Premier Dentist or The dental coverage described in this section of a Non‑Delta Dental Dentist. However, as a PPO plan, the the brochure is underwritten by Kaiser Permanente greatest benefits ‑ including out‑of‑pocket savings ‑ occur Insurance Company, a subsidiary of Kaiser Foundation when you choose a PPO Dentist. You can find Delta Dental Health Plan, Inc. (KFHP). dentists at deltadentalins.com. To use KPIC’s dental PPO insurance plan, simply make an appointment with the dentist of your choice. Be sure to give the dental office your Kaiser Federal plan ID number and social security number or Medical Record Number (MRN). Special advantages from Delta Dental dentists KPIC’s dental PPO insurance plan is administered by Delta Dental of California, and you get special advantages when you go to one of the more than 47,100 Delta Dental dentist locations in California.