2020 – 2021Dental Plan BenefitsAn overview of the dental plan benefits offered to you as aCentura Health associateCentura Health offers you a choice of two dental plans, administered throughMetLife, to make taking care of all of your dental care needs easy: thePreventive Plan and the Preferred Dental Program. You have the option toenroll in dental coverage that best fits the needs of you and your family.
Table of ContentsDental PlanEligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Your benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Accessing your benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Preventive Dental PlanDental ID cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Annual deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3This guide is intended to provide you with a generaloverview of your dental benefits. While this guideshould answer most of your questions, it does notprovide all the details of the plan. For plan details pleaserefer to the Summary Plan Description. Any informationin this guide may be subject to change. Contact thePeople Resource Center at 1-888-622-1111 if you havequestions about the benefits described in this guide.Maximum benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Filing claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3What’s covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Preferred Dental ProgramFind a MetLife dentist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Annual deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4What’s covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Dental PlanEligibilityWhat’s not covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Full-time and part-time associates budgeted to workat least 20 hours per week are eligible to participatein Centura Health’s benefit plans. Non-benefit eligibleassociates who worked 30 hours or more per week basedon Affordable Care Act (ACA) guidelines look-back periodare eligible to participate in the dental plan. You may enrollyour eligible dependents if you are also covered under theplan.Usual, customary and reasonable limits . . . . . . . . . . . . . 6Your dependents who are eligible for the plan include:Maximum benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Using a MetLife network dentist . . . . . . . . . . . . . . . . . . . . . . . 5Obtaining dental care outsideof the MetLife network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Filing claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Pre-treatment authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Filing claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Coordination of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Subrogation of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Claims and appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Administrative informationWhen coverage begins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Acquisitions and mergers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7When coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Who pays the cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Plan year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Plan sponsor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Agent for legal processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Plan administrator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Your rights as a plan participant . . . . . . . . . . . . . . . . . . . . . . 8Your responsibilities as a plan participant . . . . . . . . . . . . 8Separation of Centura Health and Centura HealthDental Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Privacy practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Your spouse, including your common-law spouse.Spouse is limited to those individuals married to anassociate either through a civil/religious marriage or acommon-law marriage recognized under Colorado law. Your civil union partner as recognized under Coloradolaw. Your child from birth, stepchild or legally adopted child,or child of whom you have legal custody (from momentof placement in the home) until, in each case, the endof the month in which the child attains age 26. Your child over age 26 who is: Mentally or physically disabled and unable to earnhis /her own living and is dependent on you for amajority of support. Proof of incapacity must beprovided to MetLife within 31 days of the date thechild’s coverage would have ended due to age. Thechild must be covered under the plan on the datejust prior to the day coverage would have endeddue to age, except during an open enrollmentperiod.Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Non-discrimination statement . . . . . . . . . . . . . . . . . . . . . . . 11Your benefitsYou may choose between two plans:2
P reventive Dental Plan P referred Dental Program (PDP)Dental ID cardsAccessing your benefitsDental cards are NOT provided, as they are notneeded in most cases. You can print a card by goingonline to My Virtual Workplace, Human Resourcessite. You also may provide your dentist with thefollowing information:Find a MetLife dentistCall MetLife at 1-800-942-0854 for the Preventive orPreferred Plan.Go online with MetLifeAccessing information about your dental plan throughMetLife’s website is easy. Simply go to www.metlife.com/mybenefits to take advantage of MetLife’s online features,including:Group Dental Insurance: MetLifeGroup Name: Centura HealthGroup Number: 303311 Dentist search — find a local MetLife dentistAnnual deductible A sk MetLife — get answers to frequently askedquestionsYou do not have an annual deductible if you participate inthe Preventive Plan. Online claim forms — download a claim form right fromyour computerMaximum benefits Dental prevention and wellness information Glossary of dental terms Current claim information Eligibility information services from a primary careproviderPreventive Dental PlanThe Preventive Plan covers preventive dental services only,including routine cleanings, exams and x-rays. You mayaccess any licensed dentist of your choice.The maximum benefit is the total amount the dental planwill pay each plan year. You are responsible for all chargesafter you reach the maximum benefit level.The maximum benefit for services in the Preventive Plan is 250 per covered person each plan year.Filing claimsYou do not have to file any claims for services performedby a MetLife dentist. If you receive care from a non-Metlifedentist, you might have to file your own claim.What’s coveredPreventive Plan Benefits Amount you pay*Preventive TreatmentNo chargeOral exam — two per plan yearCleaning — two per plan yearFull mouth X-ray — one complete set every five plan yearsBitewing X-ray — one every six monthsPanoramic X-ray — one every three plan yearsFluoride application — one per plan year for children under age 16 Sealants to posterior teeth — one treatment per tooth every three plan years for children under age 19Space maintainers — limited to non-orthodontic treatment for children under age 15Basic/Specialty TreatmentNot coveredMajor TreatmentNot coveredOrthodontia TreatmentNot covered* You will be responsible for charges above the usual, customary, and reasonable (UCR) limit when services are performed by anout-of-network dentist.Dental Plan Benefits Centura Health3
Preferred Dental Program(PDP)To find a MetLife dentist, go to www.metlife.com/mybenefits. Enter Centura Health as the company nameand follow the links to MetLife’s online provider directory.You may also call MetLife at 1-800-942-0854.The Preferred Dental Program provides comprehensivecoverage for a wide range of dental services frompreventive, basic and major care to orthodontia.Annual deductibleFind a MetLife dentistUnder the PDP, you may access any licensed dental careprovider. However, you’ll likely see lower out-of-pocketexpenses, and you won’t have to file claim forms whenyou visit a dentist who participates in the MetLife dentalnetwork.The annual deductible is the amount you pay beforethe plan begins to pay benefits for covered expenses.You do not need to satisfy the annual deductible to usepreventive and orthodontia services.You can meet your annual deductible either individuallyor as a family. The individual deductible is 50; thefamily deductible is 150.What’s coveredPreferred Dental Plan BenefitsAmount you pay*Annual ecialty 50/person, 150/familyPreventive treatment No charge/No deductibleOral exam — two per plan yearCleaning — two per plan yearFull mouth X-ray — one complete set every five plan yearsBitewing X-ray — one every six monthsPanoramic X-ray — one every three plan yearsFluoride application — one per plan year for children under age 16Sealants to posterior teeth — o ne treatment per tooth every three plan years for children under age 19Space maintainers — l imited to non-orthodontic treatment for children under age 15Emergency care — limited to care to relieve painBasic/specialty treatment20% after deductibleFillingsRoot canal treatmentRepair or re-cementing of crowns, inlays, dentures, or bridgeworkPeriodontal scaling and root planing extractionsAnestheticsOral surgeryMajor treatment50% after deductibleCrownsDenturesBridgesImplantsOrthodontia treatment Orthodontia services — limited to dependent childrenunder age 26No deductible, 50% benefit, up to 1,000 lifetime perparticipant**Benefit levels for dental care outside of the MetLife dental network are based on usual, customary and reasonable (UCR) charges. You will beresponsible for any charges above the UCR limit.Dental Plan Benefits Centura Health4
For example, all four members of one family make thefollowing deductible payments during the year: Alice 50 Ferdinand 50 Perry 20 Penelope 30This family has met the annual deductible requirement,as they have paid a total of 150.Maximum benefitsThe maximum benefit is the total amount that thedental plan will pay each year. You are responsible for allcharges after you reach the maximum benefit level. Themaximum benefit for services for the PDP is 1,500 percovered person each plan year.In addition, there is a 1,000 lifetime orthodontiamaximum benefit for each eligible dependent. Allcharges both in and out of the MetLife dental networkapply to your maximum benefit amount.Using a MetLife network dentistAs you review the summary of covered services, it’simportant to understand why and how you can benefitfrom using a MetLife dentist even though the benefitsare the same in and out of the MetLife dental network.MetLife network dentists have agreed to provideservices to Centura Health PDP participants atdiscounted contracted fees. You are responsible for onlyyour share of these reduced fees, which means you willhave lower out-of-pocket costs when you receive carefrom a MetLife dentist.have to file your own claim.Pre-treatment authorizationYour dentist should pre-authorize with MetLife anydental treatment required for services over 400.What’s not coveredThe following are examples of services and supplies notcovered by the dental plans. Contact MetLife to determineif a specific service is covered. Services or supplies received by a covered personbefore the dental expense benefits start for that person. Services not performed by a dentist except for thoseservices of a licensed dental hygienist which aresupervised and billed by a dentist and which are forscaling and polishing of teeth or fluoride treatments. Cosmetic surgery, treatment or supplies, unlessrequired for the treatment or correction of a congenitaldefect of a newborn dependent child. Replacement of a lost, missing or stolen crown, bridgeor denture. Services or supplies which are covered by any worker’scompensation laws or occupational disease laws. Services or supplies which are covered by an employer’sliability laws. Services or supplies which any employer is required bylaw to furnish in whole or in part. Services or supplies received through a medicaldepartment or similar facility which is maintained bythe covered person’s employer. Repair or replacement of an orthodontic appliance.Obtaining dental care outside of theMetLife network Services or supplies received by a covered person forwhich no charge would have been made in the absenceof dental expense benefits for that covered person.When you visit a non-network dentist, you areresponsible for your share of “usual, customary andreasonable” (UCR) charges and the entire amount theprovider charges in excess of the UCR amount. Thus,your out-of-pocket expenses may be higher when youvisit a non-network dentist. A UCR charge is the usualfee charged in the geographic area for similar dentaltreatment or supplies given by a provider of comparabletraining and experience. Services or supplies for which a covered person is notrequired to pay.Filing claimsYou do not have to file claims for in-network services.The MetLife dentist will do it for you. However, if youreceive care from an out-of-network provider, you mightDental Plan Benefits Centura Health Services or supplies which are deemed experimental interms of generally accepted dental standards. Services or supplies received as a result of dentaldisease, defect, or injury due to an act of war, or awarlike act in time of peace, which occurs while thedental expense benefits for the covered person are ineffect. Adjustment of a denture or a bridgework which is madewithin 6 months after installation by the same dentistwho installed it.5
Any duplicate appliance or prosthetic device. Use of material or home health aids to prevent decay,such as toothpaste or fluoridegels, other than topicalapplication of fluoride. Instruction fororal care such ashygiene or diet. Periodontalsplinting. Temporaryor provisionalrestorations. Temporary orprovisional appliances. Services or supplies to theextent that benefits are otherwise provided under thisplan or under any other plan which the employer (or anaffiliate) contributes to or sponsors. Implantology Charges for broken appointments. Charges by the dentist for completing dental forms. Sterilization supplies. Treatment of temporomandibular joint disorders.Usual, customary andreasonable (UCR) limitsThe amount MetLife will pay for dental services performedby a non-participating dentist is based on usual, customaryand reasonable (UCR) limits, even if your dentist charges agreater amount. MetLife determines the UCR rate basedon the normal range of charges made by dentists in yourgeographic area for the same service or supply along withthe nature and severity of the condition being treated todetermine the UCR rate.If the actual charge is less than UCR, your benefits arebased on the actual charge. If your non-participatingdentist charges more than UCR, you are responsible for thedifference.Filing claimsYour dentist will usually file the claim for you. There may betimes, such as when you use an out-of-network dentist inthe Preventive or Preferred Program, when you will haveDental Plan Benefits Centura Healthto file the claim yourself. Follow these steps to file a dentalclaim:1. Pay the non-participating dentist for the services youreceived.2. Fill out a claim form. You can download a form atMy Virtual Workplace, Human Resources site or atwww.metlife.com/mybenefits.3. Send the completed form to MetLife with theappropriate receipts and descriptions of servicesattached. Send the form to the following address forthe Preventive and Preferred Program:MetLife Dental ClaimsP.O. Box 981282El Paso, TX 79998-12824. Receive reimbursement from MetLife for eligibleexpenses.Coordination of benefitsIf you and your dependents have coverage under anotherdental plan (such as your spouse’s employer’s plan),benefits are coordinated between the two plans. Theprimary plan pays your benefits first. Then the secondaryplan pays any additional benefits that may be due.The Centura Health dental plan is always consideredprimary for you as the associate. If you are also coveredas a dependent on your spouse’s plan, that plan will besecondary. If your spouse has coverage under his/heremployer’s plan, that plan will be considered primary foryour spouse. If the other plan does not have a coordinationof benefits provision, that plan will always pay first.The Centura Health dental plan will pay expenses notpaid by the primary plan, up to the amount that wouldhave been payable under the terms of the Centura Healthdental plan had it been the primary plan.For your childrenIf your plan and your spouse’s plan cover your dependentchildren, the primary payer will be determined by the“birthday rule.” Under this rule, the plan of the parentwhose birthday falls first during the calendar year(regardless of year of birth) will be primary. (If the birthdaysof both parents are the same, the plan that has coveredeither of the parents longer is primary.)This rule does not apply in the case of separation ordivorce. Instead, determination may be based on whichparent has legal custody of the child. If a court decree hasbeen issued, the primary plan is determined by which6
parent the court decree obligates to cover the dental careexpenses of the child. Otherwise, if the parents are notmarried or are separated or divorced, the order of benefitpayment for the child is: The plan of the custodial parent The plan of the spouse of the custodial parent The plan of the non-custodial parent The plan of the spouse of the non-custodial parent.If the other plan does not have a coordination of benefitsprovision, that plan will always pay first. If none of thecircumstances already described apply, the plan that hascovered your dependents for a longer period of time willpay first.Example:Suppose your spouse incurs 500 in dental expensesand his/her plan pays 250. If the Centura Healthdental plan would have paid 300 as the primary, it willconsider paying up to 50 ( 300 – 250 50), subjectto plan provisions, toward your spouse’s expenses. Ifyour spouse’s plan pays 400, which is more than theCentura Health dental plan would have paid as theprimary, then no benefit would be paid by theCentura Health dental plan.Subrogation of benefits(MetLife’s right ofrecovery)In some situations, a third party, such as another personor insurance company, can be legally responsible for yourmedical expenses. A car accident is an example of such asituation. In cases such as these, the dental plan is entitledto repayment for all dental expenses paid.Claims and appealsIf any part of your claim for a benefit is denied and youhave questions or disagree with the judgment rendered onthe claim, you may ask to have it reviewed. In most cases,you have 60 days from the receipt of the original denial torequest a review. For more information about the claimsand appeals process, call MetLife direc
Dental Plan Benefits Centura Health 3 Preventive Dental Plan Preferred Dental Program (PDP) Accessing your benefits Find a MetLife dentist Call MetLife at 1-800-942-0854 for the Preventive or Preferred Plan. Go online with MetLife Accessing information about your dental plan through MetLife’s website is easy. Simply go to www .
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