Dental Expense Benefits
Metlife Preferred Dentist Program Plus
The following benefits are provided to all eligible Welfare Fund participants and their qualifying dependents subject to the provisions of the program.
Schedule Of Benefits
Deductible Amount
For Services of Network Providers........................... None
For Services of Non-Network Providers
Type A, B, C and/or D Expenses Combined
Individual............................................................. $100
Family.................................................................. $200
Covered Percentage
For Services of Network Providers
Type A Expenses................................................... 100%
Type B Expenses................................................... 100%
Type C Expenses................................................... 100%
Type D Expenses................................................... 75%
For Services of Non-Network Providers
Type A Expenses.................................................... 80%
Type B Expenses.................................................... 80%
Type C Expenses.................................................... 60%
Type D Expenses................................................... 50%
[When a Non-Network Provider is used, the covered expenses are based on the MetLife PDP Plus network schedule of benefits.]
Maximums
For Orthodontic Treatment
Aggregate Maximum Benefit
Lifetime per covered dependent child....................... $3,000
For Other Covered Dental Expenses
Maximum Benefit
Per Calendar Year................................................... $3,000
Please Note:
- Expenses for orthodontia, including any procedures necessary for such treatment, will be considered covered dental expenses only if the dependent child has not reached age 19.
- Covered dental expenses for orthodontia are not included in the Maximum Benefit per calendar year.
- The maximums for both orthodontic treatment and all other covered dental expenses apply to all expenses incurred whether treatment is provided by a Network Provider, a Non-Network Provider or a combination thereof.
- If a dental bill is expected to be $300 or more, see section F, Predetermination of Benefits.
Dental Expense Benefits
A. Definitons
Covered Dental Expense means the charges based on the Preferred Dentist Program Plus Schedule of Maximum Payments for the types of dental services shown in section C. These services must be:
- performed or prescribed by a dentist who is:
- a Network Provider; or
- a Non-Network Provider; and
- necessary in terms of generally accepted dental standards.
There may be more than one way to treat a dental problems. If, in MetLife's view, an adequate method or material which costs less could have been used, the dental expense benefits will be based on the method or material which costs less. The balance of the cost will not be a covered dental expense. See section E for examples that show how this works.
Dentist means a person licensed by law to practice dentistry. A type of dental service which is performed or prescribed by a doctor will be considered for dental expense benefits as if it were performed or prescribed by a dentist.
Deductible Amount means the amount shown in the Schedule Of Benefits. The deductible amount during any one calendar year will apply to covered dental expenses after:
- you incur covered dental expenses for covered persons in your family; and
- those expenses, when applied to the deductible amount, equal the family deductible amount.
Covered Percentage means the percentage shown in the Schedule Of Benefits.
Preferred Dentist Program Plus Schedule of Maximum Payments means MetLife's fee agreement with a Network Provider in which such Network Provider has agreed to accept a schedule of maximum fees as payment in full for services rendered.
Preferred Dentist Program Plus means MetLife's program to offer a covered person the opportunity to receive dental care from dentists who are designated by MetLife as Network Providers. When dental care is given by Network Providers, the covered person will generally incur less out-of-pocket cost for the services rendered.
Network Provider means a dentist who has been selected by MetLife for inclusion in the Preferred Dentist Program. These Network Providers agree to accept the Preferred Dentist Program Schedule of Maximum Payments as payment in full for services rendered.
Non-Network Provider means a dentist who is not a Network Provider.
Preferred Dentist Program Plus Directory means the list which consists of selected dentists who:
- are located in the covered person's area; and
- have been selected by MetLife to be Network Providers and part of the Preferred Dentist Program. These Network Providers agree to accept our Preferred Dentist Program Schedule of Maximum Payments as payment in full for services rendered.
B. Coverage
1. When Benefits May Be Payable
MetLife will pay dental expense beneftis if you incur covered dental expenses:
- for a covered person during any calendar year; and
- while you are covered for the dental expense benefits for that covered person; and
- the covered dental expenses are more than the deductible amount when using Non-Network Providers.
An expense is "incurred" on the date the dental service is completed.
2. How Benefits Are Determined
Benefits will be equal to the covered percentage of those covered dental expenses which are more than the deductible amount. However:
- The sum of all benefits for all covered dental expenses incurred for a covered person during any calendar year will not be more than the maximum benefit per calendar year; and
- The sum of all benefits for all covered dental expenses incurred for a covered person for orthodontic treatment during all calendar years will not be more than the applicable Aggregate Maximum Benefit.
In order to determine the amounts of covered dental expenses, MetLife may ask for x-rays and other diagnostic and evaluative materials. If they are not submitted, MetLife will determine covered dental expenses on the basis of the information which is available. This may reduce the amount of benefits which otherwise would have been payable.
3. How the Preferred Dentist Program Plus Works
A covered person is always free to choose the services of a dentist who is either:
- a Network Provider; or
- a Non-Network Provider.
Benefits will be determined and paid in either case, except that the covered person will generally incur less out-of-pocket cost if a Network Provider is chosen.
C. Dental Services Which May Be Covered Dental Expenses
1. Type A Expenses
a. Oral exams
b. X-rays:
a. full mouth x-rays but not more than once every 36 months
b. bitewing x-rays but not more than twice in any calendar year (every 183 days).
c. Preventive treatment:
a. cleaning and scaling of teeth (oral prophylaxis) but not more than twice in any calendar year; and
b. topical fluoride treatment for a dependent child until their 19th birthday, but not more than twice in any calendar year.
d. Space maintainers for a dependent child through the year in which they turn 19 (age 23 if a full-time student).
e. Two applications of sealant material for each molar tooth of a dependent child under age 16 not more than twice in a lifetime.
f. Emergency palliative treatment
2. Type B Expenses
a. Fillings - amalgam, silicate, acrylic, synthetic porcelain or composite fillings.
b. Extractions
c. Root canal treatment
d. Treatment of periodontal disease and other diseases of the gums and tissues of the mouth.
e. Oral surgery
f. Injections of antibiotice drugs
g. Administration of general anesthesia, when medically necessary in connection with oral surgery, extractions, or other covered dental services.
h. Relinings and rebasings of existing removable dentures, but not more than once in any 36 month period.
i. Repair or re-cementing of crowns; inlays or onlays; dentures; or bridgework.
3. Type C Expenses
a. Those services needed to replace one or more natural teeth which are lost while dental expense benefits for the covered person are in effect for:
a. Installation of fixed bridgework done for the first time.
b. Installation for the first time of a partial removable denture or a full removable denture.
b. Replacing an existing removable denture or fixed bridgework if it is needed because of the loss of one or more natural teeth after the existing denture or bridgework was installed or it is needed because the existing denture or bridgework can no longer be used and the existing denture or fixed bridgework was installed at least 60 months prior to its replacement.
c. Replacing an existing immediate temporary full denture by a new permanent full denture when the existing denture cannot be made permanent; and the permanet denture is installed within 12 months after the existing denture was installed.
d. Adding teeth to an existing partial removable denture or to bridgework when needed to replace one or more natural teeth removed after the existing denture or bridgework was installed.
e. Inlays, onlays, and crown restorations, but not more than one such restoration to the same tooth surface within 60 months of the prior restoration.
4. Type D Expenses
Orthodontia, including appliance therapy for dependent children through the year in which they turn age 19. The Aggregate Maximum Benefit for orthodontia is shown in the Schedule Of Benefits.
D. Exclusions: Services Which Are Not Covered Dental Expenses
- Services or supplies received by a covered person before the dental expense benefits start for that person.
- Services not performed by a dentist except for those services of a licensed dental hyienist which are supervised and billed by a dentist and which are for:
- cleaning and scaling of teeth; or
- fluoride treatments.
- Cosmetic surgery or supplies. However, any such surgery or supply will be covered if:
- it otherwise is a covered dental expense; and
- it is required for reconstructive surgery which is incidental to or follows surgery which results from a trauma, an infection or other disease of the involved part; or
- it is required for reconstructive surgery because of a congenital disease or anomaly of a dependent child which has resulted in a functional defect.
- Replacement of a lost, missing or stolen crown, bridge or denture.
- Repair or replacement of an orthodontic appliance.
- Services or supplies which are covered by any workers' compensation laws or occupational disease laws.
- Services or supplies which are covered by any employers' liability laws.
- Services or supplies which any employer is required by law to furnish in whole or in part.
- Services or supplies received through a medical department or similar facility which is maintained by the covered person's employer.
- Services or supplies received by a covered person for which no charge would have been made in the absence of dental expense benefits for that covered person.
- Services or supplies for which a covered person is not required to pay.
- Services or supplies which are deemed experimental in terms of generally accepted dental standards.
- Services or supplies received as a result of dental disease, defect or injury due to an act of war, or a warlike act in time of peace, which occurs while the dental expense benefits for the covered person are in effect.
- Adjustment of a denture or bridgework which is made within 6 months after installation by the same dentist who installed it.
- Any duplicate appliance or prosthetic device.
- Use of materials to prevent decay other than fluorides and sealant material for the molar teeth of a dependent child under age 16.
- Instruction for oral care such as hygiene or diet.
- Periodontal splinting.
- Services or supplies to the extent that benefits are otherwise provided under this plan or under any other plan which the employer (or an affiliate) contributes to or sponsors.
- Myofunctional therapy or correction of harmful habits
- Implantology.
- Initial installation of a denture or bridgework to replace one or more natural teeth lost before the dental expense benefits started for the covered person.
- Charges for broken appointments.
- Charges by the dentist for completing dental forms.
- Sterilization supplies.
- Services or supplies furnished by a family member.
- Treatment of temporomandibular joint disorders.
Dental expenses will be based on the materials and method of treatment which cost the least and which, in MetLife's view, meet generally accepted dental standards.
E. Examples Of Alternate Benefits
1. Fillings: Inlays, Onlays and Crowns
If a tooth can be repaired by a less costly method than an inlay, onlay or crown, dental expense benefits will be based on the adequate method of repair which costs the least.
2. Crowns, Pontics and Abutments
Veneer materials may be used for front teeth or bicuspids. However, dental expense benefits will be based on the adequate veneer materials with cost the least.
3. Bridgework and Dentures
Dental expense benefits will be based on the adequate method of treating the dental arch which costs the least. In some cases removable dentures may serve as well as fixed bridgework. If dentures are replaced by fixed bridgework, the dental expense benefits will be based on the cost of a replacemetn denture unless adequate results can only be achieved with fixed bridgework.
These are not the only examples of alternate benefits. To find out how much your dental expense benefits will be, see section F.
F. Predetermination Of Benefits
If a dental bill is expected to be $300 or more, before the dentist starts the treatment, a covered person can find out what dental expense benefits will be paid by MetLife. To do this, the covered person should send a claim form to MetLife in which the dentist states:
- the work to be done; and
- what the cost will be.
MetLife will then tell the covered person what the dental expense benefits schedule is. The predetermination does not review eligibility for services which have time limitations, ex. dentures cannot be replaced within 5 years of installation. If the covered person does not use this method to find out what dental expense benefits MetLife will pay, the decision will be final and binding with regard to what are covered dental expenses and what dental expense benefits will be paid.
This method should not be used for:
- emergency treatment; or
- routine oral exams; or
- x-rays, cleaning and scaling, and fluoride treatments: or
- dental services which cost less than $300.
G. Impact Of Government Plans On Dental Expense Benefits
To the extent that services or supplies, or benefits for them, are available to a covered person under a government plan, as defined below, they will not be considered for dental expense benefits under this benefit program. This provision will apply whether or not the covered person is enrolled for all government benefits for which they are eligible. This provision will not apply to a government plan if it requires that dental expense benefits under this benefit program be paid first.
A government plan is any plan, program or coverage, other than Medicare:
- which is established under the laws or the regulations of any government; or
- in which any government participates other than as an employer.
H. Dental Expense Coverage After Benefits End
No benefits will be payable for covered dental expenses incurred by a covered person after the dental expense benefits for that person end. This will apply even if we have per-determined benefits for dental services. However, benefits for covered dental expenses incurred for a covered person for the following services will be paid after dental expense benefits end:
- For a prosthetic device if:
- the dentist prepared the abutment teeth and made impressions while dental expense benefits for the covered person were in effect; and
- the device is installed within 60 days after the date dental expense benefits end; or
- For a crown if:
- the dentist prepared the tooth for the crown while the dental expense benefits for the covered person were in effect; and
- the crown is installed within 60 days after the date the dental expense benefits end; or
- For root canal therapy; if
- the dentist opened the tooth while the dental expense benefits for the covered person were in effect; and
- the treatment is finished with 60 days after the date the dental expense benefits end.
I. Payment Of Benefits
MetLife will send payment directly to your Network Provider. When a Non-Network provider is used, dental expense benefits will be paid to you. MetLife will pay benefits when it receives satisfactory written proof of your claim. Proof must be submitted no later than 90 days after the end of the calendar year in which the covered dental expenses were incurred. If proof is not given on time, the delay will not cause a claim to be denied or reduced as long as the proof is given as soon as possible.
When Benefits End
- All of your benefits will end on the date your coverage in the Welfare Fund ends. Your coverage ends when you fail to maintain eligibility. Please refer to the ELIGIBILITY section for details.
- If this benefit program ends in whole or in part, your benefits which are affected will end.
- All benefits on account of a qualifying dependent will end on the last day of the calendar year in which that qualifying dependent ceases to be your dependent.
The end of any type of benefits on account of a covered person will not affect a claim which is incurred before those benefits ended.
The dental expense benefits for a covered person may be continued in accordance with the federal law called COBRA. Please refer to the answer to the question "What Happens If I Lose Coverage?" under the ELIGIBILITY section of this booklet for details.
