Dental Insurance

New employees and their dependents are eligible for dental insurance on the first of the month following 3 months of continuous employment.
During the year, if you have a qualifying event (marriage/divorce/new child/etc.), you will have 30 days from the date of the qualifying event to make a change to your benefit election. If you do not request the change within 30 days, the next opportunity you will have to make changes to your benefit will be at the next Open Enrollment period.
Newborns must be added within 31 days of their birth, or within 31 days of their ND birthday. If not added within those times, the child will have to wait to be added at the next Open Enrollment period.
Dependent children ages 19 up to age 25 qualify for continued coverage in the employees dental plan if they are unmarried, primarily supported by the employee, and enrolled in a secondary school, college or university as a full time student. Student Verification paperwork will have to be completed.

It is the employees' responsibility to notify HR when their child is no longer a full time student. The child must be removed from your Dental Insurance effective the last day of the month of graduation or date child left school.

BENEFIT COVERAGES & PERCENTAGES PAID BY DELTA DENTAL

Diagnostic & Preventative	100%
Basic	60%
Major - includes implant services	50%

MAXIMUM BENEFIT:

The maximum amount which your plan will pay is $1,500 per person per calendar Year for Diagnostic & Preventative, Basic and Major benefits.

INFORMATION

FORMS

Delta Dental Outline of Benefits
Delta Dental Outline of Benefits.
Delta Dental Plan Booklet
Detailed booklet explaining your dental coverage; what is covered and at what percentage is it covered, etc.
Delta Dental Provider Directory
A directory of participating Delta Dental Dentists.
Delta Dental Vision Discount Program
Free Vision Discount Program offered by Delta Dental. Great savings of up to 35%.
Instructions to Log into Delta Dental
Instructions on how to Log into Delta Dental as a subscriber and how to search for a provider.
Contact Delta Dental:

Northeast Delta Dental Plan
One Delta Drive
P.O. Box 2002
Concord, NH 03302-2002

Customer Service/Lost Card: (603) 223-1234
Claim Issues Customer Service: (800) 832-5700

Authorization Form
Fill out this form if you want to authorize another person to provide, or receive dental information on your behalf.
Dental Enrollment/Change Form
This form is for All Employees EXCEPT Aldermen and Department Heads.
Use this form to add dental insurance as a new employee, or when you have a qualifying event and need to add or cancel your dental insurance or add or remove a dependent.
Dental Enrollment/Change Form 80%/ 20%
This form is for Aldermen and Department Heads ONLY.
Use this form to add dental insurance as a new Aldermen or Department Head, or when you have a qualifying event and need to add or cancel your dental insurance or add or remove a dependent.
Student Verification
If enrolling a child on your Dental who is between the age of 19 through 25 complete this form and submit the appropriate backup to show that the child is a full time student.