MMC Benefits Handbook
What's Covered
The following table summarizes the benefits the Plan pays for certain services. Participants can either use an in-network or an out-of-network provider.
For more detailed information on covered services, including information on co-payment amounts, please refer to "Covered Service Benefits and ADA Codes."
|
Premier Dental Option
|
Standard Dental Option
|
|||
|
Plan Feature
|
In-Network
|
Out-of-Network
|
In-Network
|
Out-of-Network
|
|
Plan Payment
|
Preventive and diagnostic—100%
Basic Restorative—80%
Major Restorative—50%
|
Preventive and diagnostic—100% of reasonable and customary charges (R&C)
Basic Restorative—80% of R&C after deductible
Major Restorative—50% of R&C after deductible
|
Preventive and diagnostic—100%
Basic Restorative—80%
Major Restorative—50%
|
Preventive and diagnostic—100% of reasonable and customary charges (R&C)
Basic Restorative—80% of R&C after deductible
Major Restorative—50% of R&C after deductible
|
|
Orthodontia
|
50%
|
50% of R&C
|
Not covered
|
|
|
Orthodontia lifetime maximum
|
$2,500 per covered individual (combined in-network and out-of-network)
|
N/A
|
||
|
Annual maximum
|
$2,500 per covered individual (combined in-network and out-of-network)
|
$1,500 per covered individual (combined in-network and out-of-network)
|
||
|
Lifetime maximum
|
None
|
None
|
||
A more detailed list of covered services with general information is provided below.
Anesthetics
Does the Plan cover anesthetics?
The Plan covers:
- separate charges for medically necessary general anesthetics with oral and periodontal surgery
- charges for local anesthetics included in the allowances for treatments requiring local anesthesia.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the anesthetics exclusions?
The Plan does not cover:
Cleanings and Oral Examinations
Does the Plan cover oral examinations and cleanings?
The Plan covers oral examinations and cleanings twice per calendar year.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the oral examinations and cleanings exclusions?
Refer to "What's Not Covered" for details.
Crowns
Does the Plan cover crowns?
The Plan covers:
- crowns and gold fillings only if a tooth, broken down by decay or injury, cannot be reconstructed by any other filling material
- replacement crowns and gold fillings.
The Plan has a crown time limit. Replacement crowns will be covered only if the existing crown was installed at least 84 months before its replacement.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the crown exclusions?
The Plan does not cover:
- facing or veneers on molar teeth. Full cast or amalgam restorations are covered
- reimbursement for a temporary and a permanent crown is limited to the permanent crown charge.
Refer to "What's Not Covered" for details.
Drugs
Does the Plan cover drugs?
The Plan only covers therapeutic drug injections. Any prescriptions you may receive from your dentist generally would be covered under the rules of your medical plan's prescription plan.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the Plan's drug exclusions?
The Plan only covers therapeutic drug injections.
Refer to the "What's Not Covered" section for details.
Emergency Treatment
Does the Plan cover emergency treatment?
The Plan covers emergency care to relieve pain when no other dental treatment is rendered. If any other treatment, except X-rays, is given, the benefit is based on that treatment.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the emergency treatment exclusions?
Refer to "What's Not Covered" for details.
Endodontic Treatment (Root Canals)
Does the Plan cover endodontics?
The Plan covers root canal therapy and other endodontics treatments.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the endodontics exclusions?
There are no specific endodontic exclusions.
Fillings
Does the Plan cover fillings?
The Plan covers silver (amalgam), porcelain, resin/composite and plastic fillings to restore the structure of teeth broken down by decay or injury.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
Fluoride Applications
Does the Plan cover fluoride applications?
The Plan covers fluoride applications once per calendar year for children under age 19.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the fluoride applications exclusions?
The Plan does not cover fluoride treatment for individuals age 19 or above.
Refer to "What's Not Covered" for details.
Oral Surgery and Extractions
Does the Plan cover oral surgery and extractions?
The Plan covers all extractions and other oral surgery.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the oral surgery and extractions exclusions?
The Plan does not cover:
- oral surgery postoperative care
- oral surgery treatment of fractures and dislocations (may be covered under your Medical Plan).
Refer to "What's Not Covered" for details.
Orthodontia
Does the Plan cover orthodontia?
The Premier option covers orthodontia; there is no coverage for orthodontia under the Standard option.
The Premier option covers the following orthodontia services:
- diagnostic procedures
- appliance therapy, including Invisalign
- functional/myofunctional therapy to correct position of teeth.
The Premier option covers orthodontia for employees and covered family members.
Before undergoing any specialized technique or personalization (e.g. clear braces), make sure to contact MetLife to obtain a predetermination of benefits to see what, if anything, the Plan will cover.
If you use an in-network dentist with the Premier option, the Plan pays 50% of the provider's negotiated fee, up to a $2,500 lifetime maximum benefit. With the Premier option, the Plan pays 20% of the orthodontia lifetime maximum after the first visit, with the remainder paid in equal quarterly installments over the duration of the treatment program, up to a 24-month payment period. For orthodontia services, fees are negotiated periodically.
If you use an out-of-network dentist with the Premier option, the Plan pays 50% of reasonable and customary charges for orthodontia services up to a $2,500 lifetime maximum benefit. With the Premier option, the Plan pays 20% of the orthodontia lifetime maximum after the first visit, with the remainder paid in equal quarterly installments over the duration of the treatment program, up to a 24-month payment period. For orthodontia services, fees are negotiated periodically.
Regardless of whether you use an in-network or out-of-network dentist, consultation fees for orthodontia services are applied toward the Plan's $2,500 maximum lifetime orthodontia benefit.
Orthodontia services are not subject to a deductible.
What are the orthodontia exclusions?
The Standard option provides no coverage for orthodontia.
The Premier option doesn't cover:
- charges for continuation of orthodontic treatment that began before the employee or family member was covered by the Plan
- repair or replacement of an orthodontic appliance, including Invisalign.
Refer to "What's Not Covered" for details.
Periodontics and Periodontal Cleanings
Does the Plan cover periodontics?
The Plan covers periodontics, including periodontal surgery, to treat the gum and supporting tissues.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
Are periodontal cleanings covered by the Plan?
Yes, the Plan covers four periodontal cleanings per calendar year (or two periodontal cleanings combined with two regular cleanings) provided one or more of the following periodontal treatments has been performed in two or more quadrants:
The plan covers 80% of the MetLife provider's negotiated fee for periodontal cleanings. You are responsible for the remaining 20%.
What are the periodontics exclusions?
There are no specific periodontic exclusions.
Prosthodontics
Does the Plan cover dentures and bridgework?
The Plan covers:
- dentures or bridges to replace existing appliances, even if the teeth were extracted before coverage began
- if the appliances are more than 84 months old and cannot be made serviceable
- full or partial dentures and fixed or partial removable bridgework to replace missing natural teeth
- replacing or repairing damaged dentures and adding teeth to existing dentures.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the denture and bridgework exclusions?
The Plan does not cover:
- adjustments to dentures more than six months after installation
- specialized techniques, precision attachments, personalization or characterization of dentures
- reimbursement for a temporary and a permanent denture is limited to the permanent denture charge.
Refer to "What's Not Covered" for details.
Does the Plan cover sealants?
The Plan covers sealants once every 60 months for children under age 19, on previously unrestored, decay free permanent molars.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the sealants exclusions?
Refer to "What's Not Covered" for details.
Space Maintainers
Does the Plan cover space maintainers?
The Plan covers fixed, unilateral and removable bilateral space maintainers required for maintenance of space resulting from the premature loss of deciduous (baby) teeth, up to age 19.
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the space maintainer exclusions?
There are no exclusions.
X-rays and Pathology
Does the Plan cover X-rays?
The Plan covers:
- bitewing X-rays twice per calendar year
- full-mouth X-rays, including panoramic X-rays, once every 36 months, as part of a general examination
For information on coverage amounts and co-payments, see "Covered Service Benefits and ADA Codes."
What are the X-ray exclusions?
Frequency limitations apply to these services.
Refer to "What's Not Covered" for details.