Summary Plan Description
Medical Plan Maximums
The following services and supplies have specific maximums:
- Allergy testing – Annual maximum of 12 blood tests and 60 skin tests.
- Chiropractic care – Annual maximum of 24 spinal manipulations.
- Hearing aids – Maximum of $1,000 per ear paid in any three consecutive year period. The hearing aid benefit is not available under Retiree Coverage.
- Home health care – Annual maximum of 30 visits.
- Hospice care – Maximum of 14 inpatient days for hospice care. Skilled care in the home is limited to 60 visits. Respite care is limited to 120 hours per three-month period.
- Orthognathic surgery – Lifetime maximum of $5,000. The orthognathic surgery benefit is not available under Retiree Coverage.
- Orthotics (foot) – Maximum of $400 paid in any two consecutive year period. The orthotics benefit is not available under Retiree Coverage.
- Preventive health services – Subject to services recommended by the Affordable Care Act.
- Rehabilitative and habilitative – Annual maximum of 15 inpatient days and 30 outpatient visits.
- Skilled nursing facility – Annual maximum of 25 days. Medicare-eligible retirees and dependents are eligible for 80 coinsurance days.
- TMJ and MPDS – Lifetime maximum of $2,500. The TMJ and MPDS benefit is not available under Retiree Coverage.
Related Health & Security Content
- 2017 Summary of Material Modifications (1/31/2017)
- 2017 Summary of Material Modifications (1/1/2017)
- 2016 Summary of Material Modifications
- 2014 Summary of Material Modifications
2017 Summary of Benefits and Coverage
Delta Dental of Washington
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