for U.S.-payroll employees

The documents listed below are called a summary of material modification (SMM). An SMM explains recent updates to your plan that are not yet captured or updated in your summary plan description (SPD) since the last publication date. Be sure to review the SMM for an understanding of important plan updates.

• New address for benefits correspondence (June 1, 2020)

Review the schedule of benefits to understand basic information about your dental plan, such as benefits, copayments, deductibles, coinsurance and plan contact information.

• 2022 Dental HMO Schedule of Benefits

Chevron is legally required to provide certain notices to plan participants. These notices are posted on this website for your reference.

You are required to verify the eligibility of any new dependents you enroll in your Chevron health plans. You have up to 60 days to obtain and submit requested documentation that verifies your dependent(s) are eligible to participate in Chevron’s health benefits. If you don’t provide acceptable documentation by the deadline, your dependent(s) will be disenrolled from coverage. Learn more about this process.

If you’re enrolled in the Dental HMO Plan, you’ll be covered until the last day of the month in which your employment ends. 

• You can elect COBRA coverage for you and your covered dependents for this plan. If  you timely elect COBRA coverage, your dental coverage will be retroactive to the date your active employee coverage ended. If you wish to continue dental coverage, you must make an election to continue it.
• Dental coverage is available to eligible retirees. If you're eligible for retiree health benefits, there are different decisions and actions required of you. 
  • See if you're eligible for retiree health benefits on BenefitConnect. Go to I need to… on the top navigation, then choose Retiree medical eligibility.
  • Learn about health benefits available to eligible pre-65 retirees here.
  • Learn about health benefits available to eligible post-65 retirees here.

Your social security number can be used to identify you with Delta Dental, but we all want to avoid sharing that number whenever possible. Your Delta Dental Enrollee ID is a safer choice. It was included in your welcome kit when you initially enrolled, but it's also available from the Delta Dental website (under Eligibility Information), on your digital ID card, or by calling Delta Dental.

While your dental ID card was included in your welcome kit when you initially enrolled, you don’t need an ID card for this plan. If you don't have your ID card on hand, just tell your dental office that you’re covered by Delta Dental of California and provide your Name, Date of birth, Employer Name, and Enrollee ID number (or social security number). If you have enrolled dependents, tell them to provide your details, not their own.

You have two ways to access your ID card online and, if desired, make another print out for your use.
Option 1: Print one from your computer.

• Go to the Delta Dental website and register as a new user.
• Login to Online Services.
• Click on My ID card and print.

Option 2: Pull it up on your smartphone.

• First, if you have not already, go to the Delta Dental website and register as a new user.
• Next download and register for the mobile app.
• You can access your digital ID card any time and anywhere from the mobile app.

DeltaCare USA Network
A network is a group of independent dental care providers that have agreed with your dental plan claims administrator to charge contracted fees for services provided to plan members. With the Dental HMO you must visit your selected primary care dentist in the DeltaCare USA network*, otherwise your services aren’t covered (except for certain emergency situations). If your provider is not in the network, you will need to change providers or choose a new dental plan option to ensure that your dental services continue to be covered.

Primary Care Dentist
You must visit your selected DeltaCare USA primary care dentist to receive benefits under your Dental HMO Plan. Most services not performed by your primary care dentist must be authorized by DeltaCare. You must select a DeltaCare USA network dentist in order to access benefits under the Dental HMO Plan. 

• When you first enroll in the Dental HMO Plan, you will be auto assigned to a primary care dentist, when applicable, by DeltaCare. 
• You will receive a confirmation in the mail containing your primary care dentist name, your Enrollee ID, ID card and a description of your benefits from DeltaCare. 
• This package will also provide instructions about how you can change the primary care dentist auto assigned to you. 
• Be sure you take action right away if you want to change to another DeltaCare USA network primary care dentist.
• You can change your DeltaCare USA dentist at any time by contacting DeltaCare. (Changes requested by the 21st of the month are effective the first day of the following month.) 
• You and your covered dependents are not required to select the same network dentist.

*Open Access States
If you’re enrolled in the Dental HMO Plan with DeltaCare USA and you reside in one of the states discussed here, you’re in what is referred to as an open access state. In AK, CT, LA, ME, MS, MT, NC, ND, NH, OK, SD and VT, you can visit any licensed dentist, but you will get the most value from your benefits when you visit a network dentist. If you choose an out-of-network dentist, out-of-network benefits will apply. In WY, you must visit a network dentist to receive benefits.

If you visit a network dentist, Delta Dental dentists agree to handle all claims and paperwork for you.

If your dental care is extensive and you want to plan ahead for the cost, you can ask your dentist to submit a pre-treatment estimate. This estimate includes an overview of services covered by your dental plan and how coinsurance, deductibles and dollar maximum limits might affect your share of the cost. While it's not a guarantee of payment, a pre-treatment estimate can help you predict your out-of-pocket costs.

If you’re a new Dental HMO Plan enrollee, dental treatment in progress when your coverage begins — such as root canals, crowns or bridgework — is your or your prior carrier’s responsibility. The Dental HMO Plan covers treatment started and completed after your new plan’s effective date of coverage.

For active orthodontic treatment, you should speak to DeltaCare directly regarding your situation. In general, if you or an enrolled dependent has started orthodontic treatment under your previous dental plan, you may be able to continue that coverage if you switch to the Chevron Dental HMO Plan. Through a provision called orthodontic treatment in progress, your Dental HMO Plan may allow you to continue treatment you started under your previous dental plan. You can visit the same orthodontist and have the same coverage and copayments as your previous plan. You pay the same amount that you would have paid under your previous coverage, as long as you remain eligible for coverage under your Chevron Dental HMO Plan. If you began active orthodontic treatment prior to the effective date of your Chevron Dental HMO Plan and:

• If banding has not occurred, you are not eligible for continuous orthodontic coverage. In that case, orthodontic treatment must be provided by a DeltaCare USA network orthodontist in accordance with the copayments, limitations and exclusions defined in your Chevron Dental HMO Plan. 
• If banding has taken place, you may be eligible for continuous orthodontic coverage under your Chevron Dental HMO Plan and may continue to visit the same orthodontist upon approval. Ask your orthodontist to submit a Continuous Orthodontic Coverage Form and a claim form right away. You should have your orthodontist do this whether or not they are a DeltaCare network provider. DeltaCare will coordinate benefits as necessary with your orthodontist.

The claim should include:

• Continuous Orthodontic Care Claim Form
• Any standard dental claim form or the Delta Dental claim form
• All charges and fees (including the down payment or installments paid by your previous dental plan)
• Banding date and length of active treatment
• Brief description of the dentition, appliance (including type) and treatment
• If you are covered by more than one plan, information about the other carrier.

This plan is not available to U.S.-payroll expatriates on a resident assignment or a temporary expatriate assignment of 7 months or longer. 

Keep in mind that Delta Dental does not have a network of providers outside the U.S. so coverage will be largely limited to emergency services. For this reason, you should schedule your appointments to receive care while you’re in the U.S. Contact DentalCare USA for more information about services received outside the U.S.

If you are enrolled in the Chevron Dental PPO or Dental HMO Plan in 2024*, you're encouraged to take steps to protect your health and receive at least one preventive dental cleaning** between January 1 and December 31, 2024. If you do not participate in this preventive care measure in 2024, you will pay $120 more for your annual Dental PPO or Dental HMO Plan premium in 2025.

• Only you, the employee, are required to receive this cleaning for purposes of the dental surcharge.
• The Dental Surcharge does not apply to the Dental PPO Plan (Expatriates in the U.S.)
• The procedure codes of D4346, D1110, D4910, D4355, D4341 and D4342 are considered eligible preventive dental care; these procedures will satisfy the cleaning requirement to avoid the dental surcharge in 2023. 
• Dental HMO participants should ask their provider be sure to submit Delta's Patient Encounter Form to DeltaCare USA to ensure your cleaning can be properly verified in early 2025; Dental PPO participants do not need to do anything to report completion of your cleaning.

Verification Process
Delta Dental and the HR Service Center will conduct a separate verification process in early 2025 to determine if the dental surcharge applies to you. 

• If it is determined that the dental surcharge does in fact apply to you in 2025, the BenefitConnect website will be updated and you will be mailed a revised confirmation statement by the end of the first quarter of 2025. 
• If applicable, the $120 dental surcharge will be applied to your Chevron Dental PPO or Dental HMO Plan coverage over 20 pay periods generally beginning in March 2025. 
• The dental surcharge will appear as a separate payroll deduction line item on your pay statements.

Preventive Care Coverage
We know dental exams — like many other preventive care exams — are not exactly fun. But there’s a reason they are covered by your plan; they are important to good health. 

• Chevron’s dental plans already cover at least two preventive dental cleanings per year; that will continue in 2024. 
• Covered preventive dental services are generally 100 percent paid by your plan, with no annual maximum, deductible or copayment when you use a network provider (a copayment may apply for some dental HMOs).
• Learn more about preventive care.

* If you were hired on or after October 1, 2024 the dental surcharge does not apply to your Chevron dental coverage in 2025. The 2025 dental surcharge does not apply to legacy PDC Energy employees; however, you're required to complete the cleaning requirement in 2025 to avoid a dental surcharge in 2026.

** For participants with dentures, receive at least one oral exam in lieu of a cleaning.

If you are enrolled in the Chevron Dental PPO or Dental HMO Plan in 2023*, you're encouraged to take steps to protect your health and receive at least one preventive dental cleaning** between January 1 and December 31, 2023. If you do not participate in this preventive care measure in 2023, you will pay $120 more for your annual Dental PPO or Dental HMO Plan premium in 2024.

• Only you, the employee, are required to receive this cleaning for purposes of the dental surcharge.
• The Dental Surcharge does not apply to the Dental PPO Plan (Expatriates in the U.S.)
• The procedure codes of D4346, D1110, D4910 and D4355 are considered eligible preventive dental care; these procedures will satisfy the cleaning requirement to avoid the dental surcharge in 2023. 
• Procedure codes D4341 and D4342, often referred to as deep cleaning, are treatments for periodontal disease. Starting in 2023, these procedures will satisfy the cleaning requirement to avoid the dental surcharge in 2024.
• Dental HMO participants should ask their provider be sure to submit Delta's Patient Encounter Form to DeltaCare USA to ensure your cleaning can be properly verified in early 2024; Dental PPO participants do not need to do anything to report completion of your cleaning.

Verification Process
Delta Dental and the HR Service Center will conduct a separate verification process in early 2024 to determine if the dental surcharge applies to you. 

• If it is determined that the dental surcharge does in fact apply to you in 2024, the BenefitConnect website will be updated and you will be mailed a revised confirmation statement by the end of the first quarter of 2024. 
• If applicable, the $120 dental surcharge will be applied to your Chevron Dental PPO or Dental HMO Plan coverage over 20 pay periods generally beginning in March 2024. 
• The dental surcharge will appear as a separate payroll deduction line item on your pay statements.

Preventive Care Coverage
We know dental exams — like many other preventive care exams — are not exactly fun. But there’s a reason they are covered by your plan; they are important to good health. 

• Chevron’s dental plans already cover at least two preventive dental cleanings per year; that will continue in 2023. 
• Covered preventive dental services are generally 100 percent paid by your plan, with no annual maximum, deductible or copayment when you use a network provider (a copayment may apply for some dental HMOs).
• Learn more about preventive care.

* If you were hired on or after October 1, 2023 the dental surcharge does not apply to your Chevron dental coverage in 2024. The 2024 dental surcharge does not apply to legacy B6 employees; however, you're required to complete the cleaning requirement in 2024 to avoid a dental surcharge in 2025.

** For participants with dentures, receive at least one oral exam in lieu of a cleaning.

If you are a Dental HMO participant, remind your provider to submit Delta's Patient Encounter Form to DeltaCare USA to ensure you get credit for your preventive cleaning to avoid the dental surcharge.

If you believe the dental surcharge was assessed to you in error, dispute the surcharge assignment as follows:

1. Contact your dentist for documentation related to the preventive treatment. To be considered, the documentation must include:
   • Dental provider’s name.
   • Date of service.
   • Your name (the employee) as the patient.
   • An eligible procedure code.
2. Once you have the appropriate documentation, you must submit the documentation to Delta Dental at askdelta@delta.org. The deadline to submit a dispute is June 1 of each year.
3. You’ll receive an email verifying receipt of your dispute request. Your dispute will be reviewed in approximately 2-3 weeks, and you’ll be informed of the results of the review as follows:
   • If it is determined you have met the preventive care requirement and the dental surcharge does not apply to you, your enrollment record will be automatically updated with the HR Service Center. The HR Service Center will mail a corrected confirmation statement to you and your corrected dental surcharge status will be automatically updated on the BenefitConnect website. Any dental surcharge amounts you may have already paid this year will be processed and refunded to you on a subsequent regularly scheduled paycheck.
   • If it is determined you have not met the preventive care requirement and the dental surcharge applies to you, you will receive a written follow-up directly from Chevron.