Dental Benefit Summary MetLife Preferred Dentist Program (PDP)

Transcription

1 Dental Benefit Summary MetLife Preferred Dentist Program (PDP) CORE and BUY-UP Dental Options Note: MetLife Dental Plans require that any dental election, including declining coverage, can only be changed during even year Open Enrollment periods unless you experience a qualifying event which permits a corresponding change. MetLife and Corporate Benefit Resources: MetLife MyBenefits Web Site: MetLife Member Services: (800) Corporate Benefits: (585) Page 1 of 5

2 MetLife Preferred Dentist Program (PDP) 2017 MetLife Dental Benefits Summary 2017 Dental Employee Contributions Pay Period Coverage CORE OPTION BUY-UP OPTION Full Time Part Time Full Time Part Time Biweekly Employee $2.05 $6.14 $5.64 $8.52 spouse child(ren) $5.50 $5.78 $12.28 $14.14 $13.09 $13.75 $17.05 $19.63 Family $13.65 $20.88 $25.55 $28.98 Weekly Employee $1.03 $3.07 $2.82 $4.26 spouse child(ren) $2.75 $2.89 $6.14 $7.07 $6.55 $6.87 $8.52 $9.81 Family $6.83 $10.44 $12.78 $14.49 Note: MetLife Core and Buy-Up Dental Options require a two year enrollment lock in. Evenyear (2016, 2018, etc.) Open Enrollment periods will provide an election change opportunity. Dental Plan Benefits CORE OPTION BUY-UP OPTION Annual Maximum: Individual $1,000 per calendar year $2,000 per calendar year Orthodontic Maximum: Individual $1,000 Lifetime Maximum $2,000 Lifetime Maximum* TMJ Maximum: Individual Coverage is excluded $500 Lifetime Maximum** Annual Deductible: Individual $25*** $0 Annual Deductible: Family $75*** $0 * Buy-Up orthodontic coverage has no age restrictions for covered dependents. ** Non-surgical treatment of TMJ is limited to the Buy-up Option. *** Core Option deductibles apply only to dental services in Service Types B and C. Page 2 of 5

3 Covered Dental Expenses Covered Dental Expenses means the expense incurred by or on behalf of an employee or eligible dependent* for charges made by a licensed dentist for necessary services covered by the Plan while the patient is eligible for Plan benefits (per state regulations). Where alternate services or supplies are customarily available for such treatment, covered expenses will be limited to expenses for the least expensive service or supply resulting in professionally adequate treatment. Page 3 of 5

4 Reimbursement Schedule Type of Service In-Network MetLife Preferred Dentist Program (PDP)* Out-of-Network Non-participating Dentist** Type A - Diagnostic 100% of PDP 90% of R&C Type A - Preventative 100% of PDP 90% of R&C Type B - Basic Restorative 80% of PDP 70% of R&C Type B - Oral Surgery 80% of PDP 70% of R&C Type B - Endodontic 80% of PDP 70% of R&C Type B - Periodontic 80% of PDP 70% of R&C Type C - Major Restorative*** 50% of PDP 40% of R&C Type C - Prosthodontic 50% of PDP 40% of R&C Type C - TMJ (Available in the Buy-up Option only!) 50% of PDP ($500 lifetime maximum to include non-surgical treatment of TMJ disorders) 40% of R&C ($500 lifetime maximum to include non-surgical treatment of TMJ disorders) Type D - Orthodontics 50% of PDP 50% of R&C * Reimbursement is based on PDP fee schedule; that is the negotiated network discount. ** Reimbursement is based on Reasonable and Customary Charges (R&C). The fees used to pay claims for services rendered by non-pdp providers are determined by MetLife using their accumulated claim data. They use their 90th percentile charge to establish the R&C allowance for each procedure in a geographic area, which typically means the fee charged by 9 out of 10 dentists for the procedure in that area. *** Effective 1/1/14, employees and dependents do not have to satisfy a waiting period for teeth missing prior to Paychex dental coverage for dentures or implants. Covered Dental Services The Dental Plan offered by Paychex covers almost all dental care which is essential for the care of your teeth. Covered services include, but are not limited to, the following: Type A: Diagnostic and Preventive Services Including 1 : Prophylaxis (cleaning of teeth) - two per calendar year Oral examination - two per calendar year Bitewing x-rays- two per calendar year for children, one per calendar year for adults Fluoride Treatment, limited to one per calendar year for persons under 14 years old. One application of sealant material for each non-restored molar, limited to once every 60 months for dependents under 19 years old. Emergency Palliative Treatment Space Maintainers for dependents under the age of 19 1 A pre-treatment estimate is strongly recommended for services in excess of $ Page 4 of 5

5 Type B: Minor Restorative, Endodontic, Periodontic, and Oral Surgery Services Including 2 : The Buy-Up Option does not require a deductible. The Core Option deductible must be satisfied before Type B services are considered for reimbursement. Amalgam and Composite (white) Fillings (only 1 filling covered every 2 years) Extractions, Root Canal Therapy (excluding wisdom teeth) Surgeries of the gums or bones surrounding the teeth (only 1 every 3 years)) Intraoral Periapical and Extraoral X-rays Denture Repairs. Full mouth x-rays, limited to one every five (5) calendar years. Type C: Major Restorative and Prosthodontic Services Including 1 : The Buy-Up Option does not require a deductible. The Core Option deductible must be satisfied before Type C services are considered for reimbursement Inlays, Onlays, Crowns, Veneers limited to one every 10 years Fixed Partial Dentures and Complete Dentures, limited to one every ten (10) calendar years Rebase/ Reline of Dentures- limited to once per denture per 36 month period Wisdom Teeth, Extractions General Anesthetics TMJ - Non-surgical treatment of Temporal Mandibular Joint disorders (Available in the Buy-up Option only) Implants, limited to one every ten (10) years for same tooth position (Available in the Buy-up Option only) Type D: Orthodontic Services Including 1 : Orthodontic appliances Adjustments to appliances 2 A pre-treatment estimate is strongly recommended for services in excess of $ Page 5 of 5