Dental Coverage (2014-2018)

See Dental Benefit Highlights for a one-page summary of the covered procedures, including orthodontia coverage. The How Your Delta Dental PPO Plan Works booklet provides useful information for utilizing your dental plan benefits.

The annual maximum is $1,200 per member per calendar year. Periodontal services are limited to $400 and are applied to your annual maximum total.

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New! The State is now offering Chewsi^™ dental to its employees for savings on dental care that may not be covered by traditional dental insurance. Chewsi is a free dental app that helps employees and their families save money on out-of-pocket dental care. The app works for all procedures. There are no limits, maximums, exclusions or claim forms to complete.

Use Chewsi when:

• You or a family member need or want a dental service that isn’t covered by your dental plan, such as sealants for children, bridges, dentures and implants, teeth whitening, adult orthodontic care, night guards and more
• You or a family member has exceeded the plan year maximum, but need additional care
• You or a family member (such as dependents over age 19 who are not full-time students, or part-time employees) do not have access to insurance

There is no cost or payroll deduction to use the app. Download Chewsi in the App Store or Google Play. Visit www.chewsidental.com to learn more.

Any State employee that satisfies all of the following criteria is eligible to enroll:

• Holds a non-seasonal position
• Scheduled to work at least 20 hours per week
• Not on leave without pay (LWOP)

The following dependents are also eligible for enrollment:

• Spouse
• Domestic partner
• Children (Covered up until the end of the year that they turn age 19. Children over age 19 are covered up until the end of the year in which they turn age 25 as long as they are full-time students taking 12 or more credits and submit annual school certifications; see the "Enrollment" tab for more information.)

Enrollment periods

Employees may enroll in dental coverage during one of the following periods:

• Within 31 days of hiring or a qualifying status change
• Open enrollment (the month of November)

Enrollment process

Note: You only need to submit one copy of the following form(s) and documentation to the OEB if you are also enrolling in medical and/or vision coverage.

Step 1: Required form
Complete and submit the Health Coverage Enrollment/Status Change Form to the OEB.

Step 2: Required supporting documentation
Supporting documentation must also be submitted with the Health Coverage Enrollment/Status Change Form for the following circumstances:

• Spouses
• Dual state-employed spouses
  If two spouses are both state employees—i.e., an employee answers “Yes” in section 7 of the Health Coverage Enrollment/Status Change Form, they must also complete and attach the Dual State-Employed Spouses Declaration Form.
• Divorce
  Per statute, the State employee health plan cannot provide coverage to a non-state-employee former spouse. For all divorces occurring subsequent to December 31, 2013, employees must report the divorce as a status change on the Health Coverage Enrollment/Status Change Form; the non-state-employee former spouse will be dropped from coverage and offered COBRA.
• Domestic partnerships
• Employees must attach a completed copy of the Domestic Partnership Form with supporting evidentiary documentation in order to enroll a domestic partner in medical/prescription/dental/vision coverage.
• Note: The fair market value of the state’s contribution towards the cost of health coverage for a domestic partner is considered imputed income to the employee, and must be reported as taxable income on the employee’s bi-weekly paycheck unless the domestic partner qualifies as a dependent of the employee under the IRS rules and regulations for health plans. Click here to see an example of how to calculate imputed income.
• Children
• Employees must attach a copy of their child’s birth certificate to the Health Coverage Enrollment/Status Change Form in order to enroll a child for dental coverage.
• Children between age 19–25 who are full-time students: Proof of full-time student status must be submitted along with the Health Coverage Enrollment/Status Change Form when enrolling your dependent.
• Acceptable proof: Official school class schedule showing current enrollment in classes with at least 12 credits, tuition bill showing full-time enrollment, or letter from registrar indicating full-time enrollment. The dependent child’s name and the name of the school must be on the document.
• Unacceptable proof: Financial aid award letter or school acceptance letter.
• If your dependent did not attend school in the fall semester, their coverage will terminate December 31, 2017, but they will be able to recertify as a full-time student if they return to school in the spring semester. This case is considered a status change, and your dependent would have 31 days from the start of the semester to submit a Health Coverage Enrollment/Status Change Form and proof of full-time student status to the Office of Employee Benefits. In this event, your dependent’s coverage would not be activated retroactively to December 31, 2017, but rather as of the beginning of the pay period in which the status change request is received. Your dependent would receive a COBRA election form after the termination on December 31, 2017, and they could elect COBRA coverage to fill the gap until their return to full-time student status.

See below for 2018 premium rates—i.e., your co-share—for your dental coverage.

A co-share is the amount you must pay each pay period for health insurance. Co-shares vary by individual vs. family coverage, as well as by annual salary and full-time/part-time status. Co-shares listed here are for classified and unclassified State employees only. College employees should refer to their college/university website (URI, RIC, CCRI) for their co-shares.

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Individual plans (bi-weekly co-shares)

Full-time or part-time** employees

Annual Base Salary	Percentage*	Co-Share
Less than $110,594	20%	$2.95
$110,594 and above	25%	$3.69

Family plans (bi-weekly co-shares)

Full-time or part-time** employees

Annual Base Salary	Percentage*	Co-Share
Less than $55,296	15%	$5.74
$55,296 to less than $110,594	20%	$7.65
$110,594 and above	25%	$9.56

* Percent of dental plan working rate.
** If your scheduled work hours are fewer than the full hours specified for your position, you will be classified as a part-time employee. Your co-share amount is determined according to the full-time annual salary for your job specification, not your part-time wages actually earned.

Please contact Delta Dental to find a participating dentist, print a replacement ID card, view claims history, or obtain other information regarding the state’s dental plan:

• Visit www.deltadentalri.com
• Call 1-800-843-3582