Arkansas State Employees Association & MetLife Are Pleased to Offer Dental Benefits to Participating Members To enroll, please complete and return the enrollment form to ASEA in the enclosed return envelope.
MetLife Group Dental Benefits With more than 45 years of experience providing dental benefits, MetLife is committed to offering dental benefits plans of superior value and service at attractive group rates. This commitment has helped MetLife become the largest administrator of dental benefit plans among all single commercial carriers. 1 providing dental plan administration for over 20 million people. 2 Freedom of Choice With MetLife, you can go to the dentist you re most comfortable with, even if he or she isn t in our network. But with more than 145,000 in-network dentist locations, there s a good chance your dentist is part of the MetLife s Preferred Dental Program (PDP) network. And if you need to find a dentist, you can easily find one in our national network. Plus, you ll be assured they ve passed a rigorous selection process. In fact, 98% of patients who visited an in-network dentist were satisfied with the quality of care they received. 3 Lower Costs The MetLife PDP offers you plan benefits based on negotiated fees that typically range from 15% to 45% less than the average fees for the same or similar services charged by dentists in your area. 4 All PDP dentists have agreed to MetLife negotiated fees for in-network services even for those services not covered by your plan and those provided after you ve exceeded your annual benefits maximum. Best of all, MetLife s leading network of dental providers includes more than more than 1,350 carefully screened dentists in Arkansas. 5 To find out if your dentist participates in MetLife s PDP, go to www.metlife.com/dental or call 1-800-ASK 4 MET (1-800-275-4638). Premium Costs Weekly Bi-Weekly Semi-Monthly Monthly Member $6.02 $12.05 $13.05 $26.10 Member + One Dependent $11.75 $23.50 $25.45 $50.90 Member + More Than One Dependent $20.70 $41.40 $44.85 $89.70 IMPORTANT COVERAGE INFORMATION Who is Eligible? You are eligible to enroll if you are a member of the Arkansas State Employees Association (ASEA). You may also enroll your spouse, and/or unmarried children, stepchildren and adopted children whom you support and who are under age 19, or age 23 if a full-time student. What is the Deductible? The deductible is the amount you must initially pay for covered services during a benefit period, before benefit payments will be made. Once you have met the deductible, you do not have to pay it again until the following calendar year. The deductible only applies to Basic and Major (Type B & C) services, not Preventative services. Under this plan, the annual deductible $50 (individual); $150 (family). 1 2 3 2009 MetLife Market Research, based on enrolled lives as of December 31, 2008. MetLife data as of December, 2010. 2010 MetLife Plan Participant Satisfaction Survey. 4 5 Savings from enrolling in a dental benefits plan will depend on various factors, including how often participants visit the dentist and the cost of services covered. MetLife data as of April 23, 2011.
What is the Calendar Year Maximum? The maximum amount this insurance will pay for all Eligible Dental Expenses in any calendar year is $1,250 per person for all covered services. Covered services are grouped into four categories: Preventive (Type A); Basic (Type B); Major (Type C); and Orthodontia (Type D). Benefit Highlights Type A Preventive Oral Exams (not more than 2 in 12 consecutive months) Full Mouth X-rays (once per 60 months) Bitewing X-rays (Adults: once per calendar year. Children: Twice per calendar year) Intraoral periapicals and extraoral X-rays (once per 60 months) Prophylaxis/Cleaning (no more than 2 in 12 consecutive months) Fluoride Treatments (not more than 1 in 12 consecutive months for dependent child to age 16) Sealants (no more than one application of sealant material for each non-restored permanent 1st and 2nd molar tooth of a dependent child to age 15, once every 60 months) Space Maintainers (no more than one per lifetime per area for premature loss of primary teeth for dependent children to age 18) Palliative Care Type B Basic Fillings (amalgam, resin, sedative) Repairs of Dentures and simple repairs of cast restorations Rebases/Relines (no more than one per 36 months (minimum is 6 months after initial installation) Simple Extractions General Anesthesia or IV sedation in connection with oral surgery, extractions or other covered services when determined that anesthesia is necessary in accordance with generally accepted dental standards Consultations (no more than twice in 12 consecutive months) Prefabricated Stainless Steel and Resin Crowns (replacement on same tooth surface no more than once every 5 years) Type C Major (12 month waiting period) All Other Crowns (once per 60 months) Dentures (Replacement no more than once per 60 months) Bridges (Replacement no more than once per 60 months) Harmful Habit Appliance Endodontics/Root Canal (once per tooth per lifetime) Periodontal maintenance where periodontal treatment has been performed (no more than 4 times in any year less the number of teeth cleanings received during such 12-month period) Periodontic scaling and root planing (not more than once per quadrant in any 24-month period) Pulp Capping/ pulpal therapy (excluding final restoration) Root canal treatment (once every 24 months for same tooth) Periodontal surgery (one surgical procedure every 36 months) Initial installation of full or removable Dentures (for missing congenital teeth) For loss of natural teeth removed while this Benefit Plan was in effect for the covered person, initial installation of full or removable Dentures and addition of teeth to partial removable Denture Post and cores (once per tooth in any 60 month period) Repair of implants (once in a 12 month period) Implant supported prosthetics (once for the same tooth in any 60 month period) Surgical Extractions Oral Surgery Implants Type D Orthodontia (12 month waiting period) Orthodontic Diagnostics Orthodontic Treatment Note: Orthodontic treatment generally consists of initial placement of an appliance (benefit limited to 20% of Maximum Benefit Amount for Orthodontia) and periodic follow-up visits. Follow up visits are paid quarterly if dental insurance is in effect for the person the orthodontic treatment. Orthodontia benefits are reduced if the initial placement and/or periodic follow-up visits commenced prior to this Dental Insurance being in effect for the person receiving treatment. See your SPD for more details. In-Network Benefits 100% 80% Out-of-Network Benefits 100% 80%
MetLife Dental Plan Reimbursement The Plan available to participants in the Arkansas State Employers Association (ASEA) offers a competitive benefit reimbursement. Benefit reimbursement under this plan is based on the PDP fee schedule (Maximum Allowed Charge) for in-network services. PDP Fee Schedule: When benefit reimbursement is limited to the PDP fee schedule, it means that benefits are paid based on the negotiated PDP fee. A negotiated fee refers to the PDP fee schedule which participating dentists agree to accept as payment in full, subject to deductibles, cost-sharing and benefit maximums. Reimbursement for a service may be based on all or part of the PDP fee. Reimbursement depends on the plan chosen and the service rendered. Predetermination of Benefits MetLife will provide a pre-treatment estimate of benefits for recommended treatments that exceed $300. This service helps you better understand your coverage. A pre-treatment estimate of benefits explains which recommended procedures are covered and at what amount. You should submit the treatment plan to MetLife for review and pre-treatment estimate determination of benefits before receiving the services. Please note that these are estimates only, and final benefit determinations will be made based on the deductibles and maximums, eligibility and other plan provisions when services are actually performed as reflected in the claim submitted, in accordance with the terms of the benefit plan. Alternative Benefit If MetLife determines that a service, less costly than the Covered Service the Dentist performed, could have been performed to treat a dental condition, benefits will be paid based upon the less costly service if such service: (i) would produce a professionally acceptable result under generally accepted dental standards; and (ii) would qualify as a Covered Service. Exclusions MetLife will not pay Dental Insurance benefits for charges incurred for: n Non-surgical treatment of temporomandibular joint disorder (TMJ) n Services which are not Dentally necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature n Services for which You would not be required to pay in the absence of Dental Insurance n Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person n Services not performed 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 n Services which are primarily cosmetic (for residents of Texas, unless required for the treatment or correction of a congenital defect of a newborn child) n Services or appliances which restore or alter occlusion or vertical dimension n Restoration of tooth structure damaged by attrition, abrasion or erosion unless caused by disease n Restorations or appliances used for the purpose of periodontal splinting n Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco n Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss n Decoration or inscription of any tooth, device, appliance, crown, or other dental work n Missed appointments n Services covered under any workers compensation or occupational disease law n Services covered under any employer liability law n Services for which the employee or the person receiving such services is not required to pay n Services received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital. n Services covered under other coverage provided by the Policyholder n Temporary or provisional restorations or appliances n Prescription drugs n Services to the extent such services, or benefits for such services, are available under a Government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the Government Plan. We will not exclude payment of benefits for such services if the Government Plan requires that Dental Insurance under the Group Policy be paid first. n The following when charged by the Dentist on a separate basis: claim form completion; infection control such as gloves, mask, and sterilization or supplies; or local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide. n Dental service arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food n Services for which the submitted documentation indicates a poor prognosis n Carries susceptibility tests n Diagnosis and treatment of temporomandibular joint (TMJ) disorders n Initial installation of a Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth n Precision attachments associated with fixed and removable prostheses n Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it n Duplicate prosthetic devices or appliances n Replacement of a lost or stolen appliance or crown, inlay/onlay, or Denture n Fixed or removable appliances for correction of harmful habits n Appliances or treatment for bruxism (grinding teeth) including but not limited to occlusal guards and night guards n Repair or replacement of an orthodontic device n Intra and extraoral photographic images The benefit categories, plan provisions, limitations and exclusions described in this brochure represent an overview of Plan Benefits. This document is not a complete description of a Plan. A summary plan description will be made available following your plan s effective date, and will govern if any discrepancies exist between this brochure and the actual Certificate of Insurance.
Cancellation/Termination Coverage is subject to the terms and provisions of the Group Policy (FormGPNP99) and Certificates of Insurance (Form GCERT2000) issued to each insured member. In any state exercising extraterritorial jurisdiction, the plan will be modified to meet applicable laws. INTERMEDIARY AND PRODUCER COMPENSATION NOTICE MetLife enters into arrangements concerning the sale, servicing and/or renewal of MetLife enters into arrangements concerning the sale, servicing and/or renewal of MetLife group insurance and certain other group-related products ( Products ) with brokers, agents, consultants, third-party administrators, general agents, associations, and other parties that may participate in the sale, servicing and/or renewal of such Products (each an Intermediary ). MetLife may pay your Intermediary compensation, which may include base compensation, supplemental compensation and/or a service fee. MetLife may pay compensation for the sale, servicing and/or renewal of Products, or remit compensation to an Intermediary on your behalf. Your Intermediary may also be owned by, controlled by or affiliated with another person or party, which may also be an Intermediary and who may also perform marketing and/or administration services in connection with your Products and be paid compensation by MetLife. Base compensation, which may vary from case to case and may change if you renew your Products with MetLife, may be payable to your Intermediary as a percentage of premium or a fixed dollar amount. In addition, supplemental compensation may be payable to your Intermediary. Under MetLife s current supplemental compensation plan, the amount payable as supplemental compensation may range from 0% to 7% of premium. The supplemental compensation percentage may be based on: (1) the number of Products sold through your Intermediary during a prior oneyear period; (2) the amount of premium or fees with respect to Products sold through your Intermediary during a prior one-year period; (3) the persistency percentage of Products inforce through your Intermediary during a prior one-year period; (4) a fixed percentage of the premium for Products as set by MetLife. The supplemental compensation percentage will be set by MetLife prior to the beginning of each calendar year and it may not be changed until the following calendar year. As such, the supplemental compensation percentage may vary from year to year, but will not exceed 7% under the current supplemental compensation plan. The cost of supplemental compensation is not directly charged to the price of our Products except as an allocation of overhead expense, which is applied to all eligible group insurance products, whether or not supplemental compensation is paid in relation to a particular sale or renewal. As a result, your rates will not differ by whether or not your Intermediary receives supplemental compensation. If your Intermediary collects the premium from you in relation to your Products, your Intermediary may earn a return on such amounts. Additionally, MetLife may have a variety of other relationships with your Intermediary or its affiliates that involve the payment of compensation and benefits that may or may not be related to your relationship with MetLife (e.g., consulting or reinsurance arrangements). More information about the eligibility criteria, limitations, payment calculations and other terms and conditions under MetLife s base compensation and supplemental compensation plans can be found on MetLife s Web site at www.metlife.com/brokercompensation. Questions regarding Intermediary compensation can be directed to ask4met@metlifeservice.com, or if you would like to speak to someone about Intermediary compensation, please call (800) ASK 4MET. In addition to the compensation paid to an Intermediary, MetLife may also pay compensation to your MetLife sales representative. Compensation paid to your MetLife sales representative is for participating in the sale, servicing, and/ or renewal of Products, and the compensation paid may vary based on a number of factors including the type of Product(s) and volume of business sold. If you are the person or entity to be charged under an insurance policy or annuity contract, you may request additional information about the compensation your MetLife sales representative expects to receive as a result of the sale or concerning compensation for any alternative quotes presented, by contacting your MetLife sales representative or calling (866) 796-1800. L0611185224(exp1213)(All States) Marketed Exclusive for Arkansas State Employees Association by: Underwritten by: State Employees Benefits Corporation P.O. Box 1817 Little Rock, AR 72203 501.378.0187 Inside Pulaski County 800.950.8139 Outside Pulaski County Metropolitan Life Insurance Company 200 Park Avenue New York, NY 10166 MetLife: 800.710.6113 www.metlife.com 2012 MetLife, Inc. L0212236575(exp0413)(AR) PEANUTS 2012 Peanuts Worldwide