Dental Benefits As a benefits eligible team member, you have a choice of four dental plans: First Commonwealth/Guardian Dental Health Maintenance Organization (Dental HMO) MetLife Value Plan MetLife Preferred Dentist Program () MetLife Preferred Dentist Program with Orthodontia ( with Orthodontia). Note: The Dental HMO coverage option is not available to team members working at BroMenn locations. Dental HMO Dental HMO coverage is designed to encourage preventive dental care and the early detection of dental problems. With this option, you select and receive services from a primary care dentist in the Dental HMO network. There is no charge for preventive and diagnostic services, and all other services including orthodontia are provided at substantial savings. Each covered family member may choose a separate general dentist. First Commonwealth/Guardian selects licensed private practice dentists who meet its high standards for delivering quality dental care. To ensure quality care, a variety of credentialing processes have been implemented including in-depth, onsite facility reviews, license and malpractice insurance review, continuing education seminars, patient satisfaction surveys and ongoing peer review audits. MetLife Value Plan The MetLife Value Plan offers you an affordable option to secure the dental coverage that you and your family need. This plan allows you to choose any dentist you want for your dental care needs, but pays a higher level of benefits for services received from a dentist (see The Benefits of Seeing a MetLife PDP Participating Dentist on page 2). While there are deductibles and coinsurance amounts to pay under this plan, it does offer valuable benefits toward the cost of dental care services and it does pay 100% of the cost of preventive care services provided by a member of the MetLife Preferred Dentist Program () Network. allows you to choose any dentist you want for your dental care needs. There are deductible and coinsurance amounts to pay and claim forms to file. You ll be reimbursed when the Dental Plan Administrator receives the dental claim from the dentist. Claims will be considered if the dental expense is incurred while you are covered under the plan. When you use a dentist: You receive maximum benefits and reduce your outof-pocket costs. have agreed to discount their fees and this savings is passed along to you, reducing your out-of-pocket costs. Reimbursements are based on a negotiated fee schedule for is met. These negotiated fees are typically discounted 20-30% from reasonable and customary charges. with Orthodontia This option offers the same coverage as the, but offers something more: benefits for orthodontic services for you and your covered family members.
The Benefits of Seeing a Participating Dentist Whether you elect coverage under the MetLife Value Plan, or with Orthodontia, the benefits you receive toward the cost of covered dental services will depend on whether services are provided by a dentist (in-network) or a non dentist : When the services are provided by a dentist (in-network): You receive maximum benefits and reduce your out-of-pocket costs for covered dental services. dentists have agreed to discount their fees for covered services and this savings is passed along to you, reducing your out-of-pocket costs. As noted above, the plan pays 100% of the cost of preventive care services with no deductible and no coinsurance; for all other covered services, once you meet the annual deductible, you and the plan share the cost of these services through coinsurance, which to the discounted fee. When the services are provided by a non dentist : Your benefits will be lower and your out-of-pocket costs will be higher for dental services provided by a dentist who is not a MetLife PDP dentist. If you elect coverage under the: MetLife Value Plan: The plan will pay a lower percentage of the cost for these services through coinsurance (including the cost of preventive care) and this coinsurance will be based on the reasonable and customary (R&C) charge for services, not the discounted fee. or with Orthodontia: Your coverage will pay benefits based on the reasonable and customary (R&C) charge for services, not the discounted fee. Dental HMO MetLife Value Plan / with Orthdontia No annual maximum benefit No copayment for eligible preventive care services No deductible No claim forms to file Comprehensive benefit coverage and savings on general and specialty dental services Accessible dental care from a large network of dentists Orthodontic benefit for children and adults $750 annual maximum benefit (in-network benefits) 100% coverage for eligible preventive care services with no deductible (in-network benefits) $75 individual deductible ($225 family) with provider (in-network) and non provider Claim forms to file only at non. Discounted fee schedule if you use a provider (in-network) No orthodontic benefits Annual benefit maximum is an aggregate maximum which varies based on the level of coverage you choose Single, Single + Spouse/Partner, Single + Child(ren) or Single + Family and whether services are performed by a dentist (in-network) or by a non dentist. For details, see How an Aggregate Annual Benefit Maximum Works. 100% coverage for eligible preventive services with no deductible $25 individual deductible ($75 family) with PDP (in-network) $50 individual deductible ($150 family) with non PDP Claim forms to file only at non PDP Discounted fee schedule if you use a provider Up to $2,000 per person maximum lifetime benefit for in-network orthodontic services (up to $1,500 per person maximum benefit for out-of-network orthodontic services) under with Orthodontia; does not cover orthodontia. All four options cover the removal of complete bony impacted teeth. How an Aggregate Annual Benefit Maximum Works The annual benefit maximum under and with Orthodontia coverage is an aggregate maximum benefit. The annual benefit limit under these two plans varies based on: The level of coverage you choose Single, Single + Spouse/Partner, Single + Child(ren) or Single + Family Whether services are performed by a MetLife PDP dentist (in-network) or by a non dentist. The benefits you can receive each year if you have Single + Spouse/Partner, Single + Child(ren) and Single + Family coverage will be subject to the annual benefit maximum. As an aggregate maximum benefit, this limit will apply whether benefits are paid for covered services received by one covered family member or by two (or more) covered family members. With this approach, if one covered family member receives extensive dental services in a year, that family member s benefits will not be limited to an individual annual benefit maximum. Rather, that family member could receive up to $6,000 in benefits for in-network services (under Single + Spouse/Partner and Single + Family coverage), or up to $4,000 in benefits for in-network services (under Single + Child(ren) coverage). Note: Benefits paid to all covered family members in a year cannot exceed the applicable in-network or out-of-network annual benefit maximum. 2
Dental Plans At-a-Glance (Dental HMO is not available to team members working at BroMenn locations) MetLife Value Plan / with Orthodontia Dental HMO* (in-network) (out-ofnetwork) (in-network) (out-ofnetwork) Diagnostic/Preventive Services Oral examinations initial, periodic, emergency X-rays, intraoral, periapical, occlusal, bitewing, panoramic Cleaning/protection of teeth prophylaxis, topical application of fluoride, sealants Other preventive services space maintainers Individual/Family Deductible Other Features No copayment No copayment No copayment $36 $54 copayment Plan pays 100% of negotiated rate Plan pays 70% of R&C charges. You pay any amount in excess of R&C charges Plan pays 100% of negotiated rate No deductible $75/$225 $75/$225 $25/$75 $50/$150 Claim forms required No Yes Yes Yes Yes Pre-existing condition exclusions No Yes Yes Yes Yes Pre-estimate review No Yes Yes Yes Yes Subject to R&C limits No Yes Yes Yes Yes Annual benefit maximum No annual limit $750 per person $500 per person Plan pays 100% of R&C charges. You pay any amount in excess of R&C charges Single $3,000 $1,500 Single + Spouse/Partner $6,000* $2,500* Single + Child(ren) $4,000* $2,500* Single + Family $6,000* $3,000* Basic Dental Services Minor restorative amalgams, composite resin filling Endodontics pulp caps and pulpotomies/ pulpal therapy $26 $68 * $12 $180** copayment Plan pays 50%, you pay 50% of negotiated rate after deductible Plan pays 35%, you pay 65% plus any amount in excess of R&C charges after deductible Plan pays 80%, you pay 20% of negotiated fee after deductible pay 20% plus any amount in excess of R&C charges after the deductible *As an aggregate annual maximum benefit, this is the maximum amount that will be paid in benefits each year for all covered family members, whether covered expenses are incurred by one family member or by two (or more) family members. ** These are ranges of copayments for services within categories; for the actual copayment amount for a particular service, refer to the current Dental HMO Copayment Schedule 3
MetLife Value Plan / with Orthodontia Dental HMO (in-network) (in-network) Periodontics periodontal maintenance procedures, periodontal sealing, gingival curettage, gingival/ osseous surgery $17 $146 pay 20% of negotiated pay 20% plus any amount Adjustments/Repairs denture adjustments, repairs, relining, rebating, recementation/repairs of crown, bridge work $14 $255 pay 20% of negotiated pay 20% plus any amount Oral Surgery simple extractions $19 $67 pay 20% of negotiated pay 20% plus any amount Oral Surgery surgical extractions of soft tissue and partially bony impacted teeth, alveoplasties $19 $67 pay Endodonticss root canals, apexification, apicoectomey and all other endodontic services $10 $180 pay Miscellaneous services general anesthesia $ 0 $55 pay Major Dental Services Prosthodontics full/ partial removable dentures $173 $778 pay Crown/bridge inlays, onlays, crowns, labial veneers, fixed bridgework $115 $550 pay Post/core/core build-ups $136 $191 pay Implants No pay Orthodontics Child braces Adult braces Pre-Orthodontic Treatment Examination Retainer $3,241 copayment $3,621 copayment $205 copayment $255 copayment : Not covered (but discount applies) with Orthodontia: Plan pays 50% up to maximum lifetime benefit of $2,000 per person : Not covered with Orthodontia: Plan pays 50% up to maximum lifetime benefit of $1,500 per person * These are ranges of copayments for services within categories; for the actual copayment amount for a particular service, refer to the current Dental HMO Copayment Schedule 4
Accessing Dental Benefits If you elect coverage under the DHMO coverage option you do not need an ID card to access dental care services from a dentist who is a member of the Dental HMO provider network. If you are newly-enrolled for coverage under the Dental HMO: You should contact Member Services at 800.775.2246 before receiving any services to confirm you are officially listed on the January Dental HMO roster. Note: This roster will be mailed to your designated Dental HMO provider. If your name is not on the roster, the Member Services representative will confirm for you when this will occur and the earliest date for which you can schedule an appointment. If you have an urgent need to see a provider, please make this known to the Member Services representative; the representative will work to schedule your care on an urgent basis. If you elect coverage under the MetLife Value Plan or coverage option you do not need an ID card to access dental care services from a dentist who is a member of the provider network. However, MetLife has provided a printable version of an ID card which you can access through advocatebenefits.com > Login > Benefits Information > Health & Welfare > Dental Benefits > Participant Identification (ID) Card. For your convenience, this ID card includes the group number for your coverage. If you have any questions or need further assistance, you can call a MetLife Representative at 800.942.0854. / with Orthodontia Limitations & Exclusions Limitations Oral examinations, prophylaxis (routine or periodontal maintenance) and fluoride applications are limited to twice every calendar year. Fluoride applications are covered for dependent children under the age of 19 and limited to two per calendar year. Full-mouth/panoramic x-rays are limited to one every 60 months. Additional bite-wings are allowed once every calendar year. Emergency oral exams are covered only if no other services, other than palliative treatment, are billed for the same treatment session. Periodontal scaling and/or root planning is limited to once a calendar year. If more than one periodontal service is performed per quadrant on the same day, only the more complex procedure will be a covered dental benefit. Benefits for fillings are limited to silver amalgam, silicate and plastic. Temporary restorations, bases or sedative fillings are. Pulp vitality tests are limited to one every calendar year per tooth. These plans provide for crowns and replacement of missing teeth with complete or partial dentures or fixed bridges using standard procedures. Treatment involving the use of the following procedures or materials is considered optional and, if performed, the applicable fee is the responsibility of the patient to pay: Noble and high noble metal, such as gold, for crowns and removable or fixed appliances. Precision partials, precision attachments to any appliance, and copings. Personalization or characterization of any prosthetic. Crowns are provided only if there is insufficient tooth structure to retain an amalgam, silicate or plastic restoration. Crowns and bridgework are provided in the presence of sufficient breakdown or decay, and adequate bone support. Benefits for replacement of crowns, dentures, bridges, inlays, onlays and implants are limited to once every 10 years. Benefits for general anesthesia are limited to professional fees and payable only when medically necessary and administered with a covered oral surgical dental procedure by a person who is licensed to administer general anesthesia. Space maintainers are limited to fixed unilateral for dependent children under the age of 19 and not in conjunction with orthodontic treatment. Exclusions Will not pay Dental Insurance benefits for charges incurred for: Services which are not Dentally Necessary, or those which do not meet generally accepted standards of care for treating the particular dental condition; Services for which You would not be required to pay in the absence of Dental Insurance; Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; 5
Services which are neither performed nor prescribed by a Dentist, except for those services of a licensed Dental Hygienist which are supervised and billed by a Dentist, and which are for: Scaling and polishing of teeth; or Fluoride treatments; Services which are primarily cosmetic, Services or appliances which restore or alter occlusion or vertical dimension; Restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease; Restorations or appliances used for the purpose of periodontal splinting; Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco; Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss; Initial installation of a Denture or implant to replace one or more teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing teeth; Decoration or inscription of any tooth, device, appliance, crown or other dental work; Missed appointments; Services: Covered under any workers compensation or occupational disease law; Covered under any employer liability law; For which the Employer of the person receiving such services is required to pay; or Received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital; Services covered under other coverage provided by the Policyholder; Temporary or provisional restorations; Temporary or provisional appliances; Prescription drugs; Services for which the submitted documentation indicates a poor prognosis; The following, when charged by the Dentist on a separate basis: Claim form completion; Infection control, such as gloves, masks, and sterilization of supplies; or Local anesthesia, non-intravenous conscious sedation or analgesia, such as nitrous oxide; Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food; Caries susceptibility tests; Modification of removable prosthodontic and other removable prosthetic services; Appliances or treatment for bruxism (grinding teeth); Precision attachments associated with fixed and removable prostheses, except when the precision Attachment is related to implant prosthetics; Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it; Duplicate prosthetic devices or appliances; Replacement of a lost or stolen appliance, Cast Restoration or Denture; Replacement of an orthodontic device; Diagnosis and treatment of temporomandibular joint disorders and cone beam imaging associated with the treatment of temporomandibular joint disorders; Intra and extraoral photographic images; Biopsies of hard or soft oral tissue. QUESTIONS? For additional information or questions about: Dental HMO coverage call First Commonwealth/Guardian at 800.775.2246. MetLife Value Plan, or with Orthodontia coverage call MetLife at 800.942.0854. Online Dental Account advocatebenefits.com > Login > Health & Well-being > My Vendors > Dental. 6 Advocate Health Care 09/18 MC 0921