2009 Summary of Covered Dental Services

Transcription

1 2009 Summary of Covered Dental Services

2 2009 Summary of Covered Dental Services This summary shows the coverage details for the dental options offered by Xerox. It is not an all-inclusive summary of plan provisions or covered services. Dental Plan Comparison Chart You may choose from three Dental Plans: MetLife Dental, MetLife Dental Plus, and the Aetna DMO. If your dentist does not participate in your current plan's network or if there are no in-network dentists/specialists within a 25-mile radius, consider enrolling in the MetLife Dental Plus option it offers the best coverage for out-of-network service. Plan MetLife Dental Plus MetLife Dental Aetna DMO In-Network Out-of-Network In-Network Out-of-Network Not applicable to No Network Available participants. No Network Available In-Network Only Annual Deductible Annual Maximum Benefit Diagnostic/ Preventive Services Coverage Basic Restorative Services Coverage Major Restorative Services Coverage Orthodontia Coverage (children and adults) does not apply to preventive care. does not apply to preventive care. Pays up to $1,500 per person, per year, excluding orthodontia. Pays 100% with no deductible. Pays 80% after deductible. after deductible. with no deductible; $1,500 lifetime maximum benefit per covered person. Pays 100% of R&C* with no deductible. Pays 80% of R&C* after deductible. of R&C* after deductible. of R&C* with no deductible; $1,500 lifetime maximum benefit per covered person. * R&C charges: reasonable and customary charges; see definition on page 2. does not apply to preventive care. applies to all services, including preventive care. does not apply to preventive care. Pays up to $1,500 per person, per year, excluding orthodontia. Pays 100% with no deductible. Pays 80% after deductible. after deductible. with no deductible; $1,500 lifetime maximum benefit per covered person. After you meet your deductible, pays a scheduled fee allowed amounts. After you meet your deductible, pays a scheduled fee allowed amounts. Pays a scheduled fee allowed amounts (no deductible applies). After you meet your deductible, pays a scheduled fee allowed amounts. After you meet your deductible, pays a scheduled fee ZIP code); you pay allowed amounts. Pays a scheduled fee allowed amounts (no deductible applies); $1,500 lifetime maximum benefit per covered person. Pays a scheduled fee allowed amounts (no deductible applies); $1,500 lifetime maximum benefit per covered person. None. None. You pay a schedulebased copayment. You pay a schedulebased copayment. You pay a schedulebased copayment. You pay a schedulebased copayment. 1

3 What Are R&C Charges? You ll see references to reasonable and customary charges R&C charges in this brochure. R&C charges are determined by your health plan and are based on the range of fees charged by providers and facilities for the same or similar services in your area. R&C charges only apply to out-of-network care. You are responsible for paying any amounts that exceed R&C charges. MetLife Dental and Dental Plus Options Key Considerations The key difference between the MetLife Dental and the MetLife Dental Plus options is that the MetLife Dental Plus option offers greater reimbursement for out-of-network providers. If your dental provider does not participate in the MetLife network, you may want to choose the MetLife Dental Plus option because it provides a higher level of benefits. To find out if your provider participates in the MetLife network or to find one who does, call or visit and enter Xerox at the employer prompt. Please note: The MetLife dental coverage options offered by Xerox are referred to as MetLife s Preferred Dentist Program PPO. For both MetLife Dental and MetLife Dental Plus options, your cost for dental services depends on whether the provider participates in the network and whether the network is available in your area. In-network providers have agreed to charge MetLife s negotiated fees, so you don t have to worry about reasonable and customary (R&C) limits. You pay only coinsurance or nothing at all. Generally, you can save money by using an in-network dentist, and you don t have to file claims to be reimbursed. Out-of-network providers set their own rates, so you are responsible for the difference if a provider s fees are above MetLife s R&C limits. In addition, you must file claims to be reimbursed. If you choose the MetLife Dental option and there are no participating MetLife primary care dentists within a reasonable distance from your home (25 miles), you may qualify for the No Network Available Schedule. You will be responsible for the difference between the reimbursed fee and the standard charge by your provider. Because you cannot take advantage of using a MetLife primary care provider, the deductible does not apply to diagnostic/preventive services. It is strongly recommended that you enroll in the MetLife Dental Plus option if you plan to go out-of-network for dental services. If You Need Dental Care from a Specialist If you are covered under the MetLife Dental or MetLife Dental Plus option and receive care from an out-of-network specialist because no in-network specialists are available, the following applies: If there is a primary care dentist in your area, the No Network Available provisions do not apply; benefits will be paid according to the out-of-network provisions. If there is not a primary care dentist in your area, the No Network Available provisions do apply, and benefits will be paid according to the No Network Available schedule. Note that some primary care dentists will perform specialty services such as root canals and oral surgery. When to Predetermine Benefits Under the MetLife Options For the MetLife Dental and MetLife Dental Plus options, predetermination of benefits is recommended if the treatment is expected to cost $300 or more, or if the treatment includes bridgework, dentures, multiple crowns, inlays, onlays, veneers, implants, or periodontal therapy. Your dentist will submit a claim form to initiate the predetermination process. 2

4 What s Covered Under the MetLife Options Covered diagnostic and preventive services include: Oral examinations: two per plan year Oral test for mouth cancer Prophylaxis: two per plan year* Fluoride: one per calendar year for children up to age 14 Fluoride varnish Sealants: one application every five years for children up to age 19 (first and second molars only) Space maintainers: coverage for children up to age 14 X-rays: complete X-rays covered once every five years; bitewing X-rays covered once per calendar year for adults (covered twice per calendar year for children up to age 19) Emergency palliative treatment * This allows the following per calendar year: no prophylaxis plus four periodontal cleanings; one prophylaxis plus three periodontal cleanings; or two prophylaxis (two per plan year) plus two periodontal cleanings. Covered basic restorative services include: Dental consultations: one per calendar year Periapical X-rays Periodontal cleanings: four per calendar year, combined with regular cleanings* Pulp capping Pulpotomy Routine root canal therapy: one per calendar year Apicoectomy (root surgery) Molar root canal (permanent tooth) Amalgam (silver fillings) Pin retention per tooth Composite fillings Correction of occlusion Scaling and root planing per quadrant: once every 24 months General anesthesia Intravenous sedation Aveoloplasty Frenulectomy Incision and draining of abscess Uncomplicated extractions Surgical removal of erupted teeth Treatment for bruxism Periodontal surgery (includes gingivectomy and osseous surgery): once every 36 months per quadrant Crown and bridge repairs Relines: once per 24 months Denture repairs * This allows the following per calendar year: no prophylaxis plus four periodontal cleanings; one prophylaxis plus three periodontal cleanings; or two prophylaxis (two per plan year) plus two periodontal cleanings. Covered major restorative services include: Removal of soft tissue impaction Full or partial impaction Inlays/onlays/crowns: replacement once every seven years * Full and partial dentures: replacement once every seven years *MetLife conducts consultant reviews by licensed dentists for certain dental claims in order to assure that benefits requested are appropriate dental care. Crowns (abutments to bridgework): replacement once every seven years Pontics (false teeth): replacement once every 10 years Implants: subject to consultant review* 3

5 What s Covered Under the Aetna DMO Option The Aetna DMO offers coverage through a network of participating dental providers. The plan pays benefits only if you use a network provider. If you receive care from a provider who does not participate in the Aetna DMO network, you are responsible for the full amount of the provider s charges. To find out if your provider participates in the Aetna DMO network or to find one who does, call or visit With the Aetna DMO, you only pay a copayment for dental services, and you don t have to file any claims. Covered Expenses Under the Aetna DMO Option Covered diagnostic and preventive services include: Oral examinations: four times per calendar year Prophylaxis: two treatments per calendar year Fluoride: one per calendar year for children up to age 16 Sealants: one application per tooth every three rolling years for children up to age 16 (permanent molars only) Space maintainers: coverage for employees and dependents Dental consultations X-rays: bitewings limited to one set per calendar year; one full-mouth X-ray limited to one set every three rolling years; vertical bitewings limited to one set every three rolling years Periapical X-rays Oral hygiene instruction for plaque control (may include coaching for home care techniques such as tooth brushing, flossing, and use of special oral hygiene aids); does not cover the cost of aids or devices used for plaque control Covered basic restorative services include: Periodontal cleanings: as maintenance; two treatments per calendar year after surgical therapy Pulp capping Pulpotomy Routine root canal therapy Apicoectomy (root surgery) Amalgam (silver fillings) Pin retention per tooth Composite fillings Correction of occlusion Scaling and root planing per quadrant: four separate quadrants in two rolling years Removal of soft tissue impaction Gingivectomy Aveoloplasty Frenulectomy Incision and draining of abscess Uncomplicated extractions Surgical removal of erupted teeth Emergency palliative treatment Covered major restorative services include: Full or partial impaction Molar root canal (permanent tooth) Osseous surgery: one per quadrant every three rolling years Occlusive guard for bruxism: one occlusal guard per quadrant every three rolling years Inlays/onlays/crowns: replacement once every five years Full and partial dentures: replacement once every five years Crowns (abutments to bridgework): replacement once every five years Pontics (false teeth): replacement once every five years Denture reline/rebase: not covered within six months of initial installation; no frequency limits thereafter General anesthesia and intravenous sedation 4

6 What s Not Covered Here is a partial listing of some of the most frequently used services and supplies that are not covered under any of the dental options offered by Xerox: Cosmetic services and supplies Implants (Aetna DMO only; covered under the MetLife Dental and Dental Plus options, subject to consultant review) Treatment for temporomandibular joint (TMJ) syndrome Plaque-control programs (MetLife Dental options only) Bonding Metallic restorations Crown and bridge repairs (Aetna DMO only) Important The following items constitute a summary of material modifications: The 2009 Matter of Choice Enrollment Guide The 2009 Matter of Choice Making Your Benefit Elections brochure The 2009 Summary of Covered Medical Services The 2009 Summary of Covered Dental Services The 2009 Summary of Covered Vision Services The 2009 Hawaii Summary of Covered Medical Services (XMP and XMP Plus) The 2009 Medical Options Schedule of Services Coverage brochure This summary of material modifications, along with the most recent edition of the summary plan description, is only a summary of your benefit options and does not create a contract between the Company and any employee.* The official plan names of the plans affected by the changes are: The Xerox Medical Care Plan, which includes the Coinsurance, Blended, and High Deductible options; the Xerox Employee Assistance Program (XEAP); as well as the CVS Caremark Prescription Drug Program; and, in Hawaii, the Xerox Medical Plan (Hawaii XMP) and Xerox Medical Plan Plus (Hawaii XMP Plus). Xerox Insured Medical Care Plan, which includes the local Health Maintenance Organizations (HMOs)/Exclusive Provider Organizations (EPOs), and XEAP. The Xerox Dental Care Plan, which includes the MetLife Dental, MetLife Dental Plus, and the Aetna DMO options. The Xerox Vision Care Plan. Details of these plans and programs can be found in the plan documents or HR policies that govern all aspects of the plan or program or, if applicable, in the agreements between the HMOs/EPOs and the employees who elect them. In the event of a discrepancy between the information contained in this enrollment guide and the applicable HR policies, agreements, or plan documents, the relevant HR policies, HMO/ EPO agreements, or plan documents shall be controlling. The Company reserves the right to amend or terminate the plans or programs at any time for any reason. * Temporary employees (except for certain cases in Hawaii) and independent contractors, including (without limitation) leased employees, supplemental contract workers, consultants, or anyone classified as such by the Company, or any other third-party personnel, or anyone classified by the Company as such, who perform services for the Company, are neither eligible for nor covered by the plans and programs summarized herein (unless they qualify as eligible dependents). 5

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8 To find out more about making your 2009 benefits elections, visit Your Benefits Resources at or contact the Xerox Benefits Center at Xerox Corporation. All rights reserved. Xerox and the sphere of connectivity design are trademarks of Xerox Corporation in the United States and/or other countries. Your Benefits Resources is a trademark of Hewitt Management Company LLC. 09/08 H