Basic Dental Plans: 2016 Features & Benefit Details. Small Business Family and Adult plans. Massachusetts Family Basic Dental Plan

Transcription

1 PLAN NETWORK Is this a smaller network? Is there out-of-network coverage? Annual deductible one enrollee* Annual deductible family* Maximum annual out-of-pocket child under 19 yrs. Maximum annual out-of-pocket 2 or more children under 19 yrs. Maximum annual benefit adults 19 and over only Altus Dental Participating Dentists Dental MetLife Preferred Program DentalGuard Preferred Yes No No Yes No No Yes $50 $150 $350 $700 $750 *Waived for diagnostic and preventive services and for some plans, medically necessary orthodontia. Page 1 of 9

2 Dental Type I services: Preventive & Diagnostic Dental Co-insurance percentage (what you pay) All ages in-network 0% out-of-network 20% For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. Comprehensive 1 per patient per location per 2 Procedures per Evaluation patient per 12 Periodic Oral Exams Oral Evaluation under 3 Years of Age 2 Procedures per patient per Teeth Cleaning 12 Limited Oral Evaluation 2 Procedures per patient per 12 * Full Mouth X-Rays patient per Panoramic X-Rays 36 Single Tooth X-Rays Bitewing X-Rays Fluoride Treatments 2 Procedures per patient per 12 3 Space Maintainers tooth per 36 Sealants *Not combined with other covered exam procedures. 4 Procedures per 12 area per Page 2 of 9

3 Dental For enrollees 19 yrs. and over Benefit Standard Limits means that the limits are the standard limits or the equivalent. 2 Procedures per Comprehensive patient per 12 Evaluation 1 per patient per 60 Periodic Oral Exams 2 Procedures per patient per Teeth Cleaning 12 Limited Oral Evaluation 2 Procedure/s per patient per 12 * Full Mouth X-Rays Panoramic X-Rays Single Tooth X-Rays Bitewing X-Rays Periodontal Cleaning patient per 60 2 Procedures per patient per 12 patient per 3 (some restrictions Palliative Care *Not combined with other covered exam procedures. **Less the number of teeth cleanings [prophylaxis] received during that 12 month period. patient per 36 patient per 36 as Type I, see Type II for coverage details 4 Procedures per patient per 12 ** as Type II Service 2 Procedures per 12 Page 3 of 9

4 Dental Type II services: Basic Restorative Co-insurance percent (what you pay) All ages: in-network 25% out-of-network 45% For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. 4 Procedures per patient per patient per 12 Periodontal Cleaning 3 Silver Fillings tooth per White Fillings surface per 12 * * tooth per 60 Not Temporary Fillings ** Prefabricated Stainless Steel Crowns Periodontal Scaling and Root ing Root canals on permanent teeth Apicoectomy** Vital Pulpotomy Simple Extractions Surgical Extractions Anesthesia Palliative Care quadrant per 36 tooth per tooth per (pre-authorization may be required) (some restrictions (some restrictions quadrant per 24 1 proedure per tooth per Not Page 4 of 9

5 Periodontal Surgery Bridge or Denture Repair Rebase or Reline Dentures Recement Crowns and Onlays quadrant per 36 patient per 24 month ** patient per 12 *** patient per ** ** patient per *** tooth per patient per *** tooth per 12 arch per 24 * For white fillings, paid as an alternate benefit on restorations on molar teeth, MetLife. *Will not pay more for a composite restoration (white filling) on a primary (deciduous) posterior tooth than an amalgam restoration (silver filling),. **No limitation for this procedure, MetLife only. ***6 after initial placement. Less the number of teeth cleanings [prophylaxis] received during that 12 month period. Page 5 of 9

6 Dental Benefit Standard Limits means that the limits are the standard limits or the equivalent. Silver Fillings tooth per * White Fillings surface per 24 Temporary Fillings Prefabricated Stainless Steel Crowns (pre-authorization may be required) tooth per 60 * 1 procedure per tooth per 1 procedure per tooth per quadrant per 24 Periodontal Scaling and Root ing quadrant per 24 Root canals on permanent teeth tooth per Apicoectomy* tooth per Vital Pulpotomy tooth per Simple Extractions (pre-authorization Surgical Extractions may be required) Anesthesia (some restrictions (some restrictions Palliative Care quadrant Periodontal Surgery per 36 *No limitation for this procedure, MetLife only. 3 Procedures per 12 at Type I Service Page 6 of 9

7 patient per Bridge or Denture Repair 12 *** Rebase or Reline Dentures 36 arch per 36 *** arch per 24 Recement Crowns and tooth per Onlays *** tooth per 12 **For white fillings, paid as an alternate benefit on restorations on molar teeth. ***6 after initial installation. Page 7 of 9

8 Dental Type III services: Major Restorative Co-insurance percent (what you pay) Under 19: in-network 50% out-of-network 70% 19 and over: For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. Waiting period None Crown, resin tooth per 60 Porcelain/ceramic crowns tooth per 60 Porcelain fused to metal/noble/high noble crowns tooth per 60 Partial & complete dentures arch per 84 Fixed Bridges and Crowns (when part of a tooth per 60 bridge) patient per 84 * only if no other less expensive adequate dental service is available. patient per 84 patient per 84 * * * Page 8 of 9

9 Dental Type IV services: Orthodontia Co-insurance percent (what you pay) Under 19: in-network 50% out-of-network 70% 19 and over: For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. patient per Medically necessary orthodontia (pre-authorization is required) Page 9 of 9