Benefits Description
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Dental Insurance/2-9 Lives
MetLife’s dental insurance means choice, value and
quality. We offer cost-savings and efficiency through
affordable plan designs and a managed care approach to
dental insurance programs. As a leader in managed
dental care, we offer insureds the freedom-of-choice to
go to any dentist they choose, including any of our more
What’s Available
We offer the following Preferred Dentist Program “point of
service” plan designs (minimum of 2 eligible employees):
Coinsurance
Coinsurance
Deductible
In Network
(Diagnostic &
Preventive/
Basic/Major)
Out of Network
(Diagnostic & /
Preventive/
Basic/Major)
In
Out
1*
100/80/50
100/80/50
$50
$50
2*
100/80/50
80/60/40
$50
$50
100/80/25
100/80/50
100/80/25
100/80/50
$50
$50
$50
$50
3**
1st Year
2nd Year
* Deductible waived for diagnostic and preventive services for plans 1 and 2.
** Groups with no prior dental coverage or without acceptable evidence of
prior dental coverage can only choose plan 3.
Calendar Year Maximums
◆ For groups with 2–4 employees — $1,000
◆ For groups with 5–9 employees who have no prior dental
coverage — $1,000
◆ For groups with 5–9 employees with an annual dental
maximum of $1,500 in force — $1,000 or $1,500
Features
✓ Preferred Dentist Program
Our network has more than 51,000 participating dentists,
including over 11,000 specialists.
✓ Personal Savings
All of our plans allow employees to select any dentist
(in-network or out-of-network) at the time of treatment;
it is not necessary to choose a participating dentist at
enrollment. Plus, we don’t require referrals from a
general dentist to see a specialist.
✓ Easy Access to Participating Dentists
than 51,000 participating dentists.
Plan
✓ Freedom of Choice
Participating dentists accept fees that are typically 10% to
30% below the average charges for the geographic area, so
employees’ out-of-pocket costs are generally lower. In
addition, participating dentists generally extend MetLife’s
lower, negotiated fees to PDP enrollees for services not
covered under the employee’s plan.
Employees have access to customized Preferred Dentist
directory information that is mailed the next business
day following the employee’s request. To obtain a list of
participating dentists, call us toll-free at 1-800-474-7371,
or contact us on-line at http://www.metlife.com/dental.
Dentists interested in joining our network should call
1-800-METDENT.
✓ Continuity of Coverage
To prevent loss or gain of coverage when transferring
insurance carriers, we give credit for service requirements
and deductibles that were fully or partially met under a
prior carrier’s plan. However, plan maximums fully or
partially satisfied under a prior carrier’s plan will be
deducted from our plan’s maximum benefit.
✓ Claims Administration
Our state-of-the-art claims system automatically identifies
procedures and claims that require professional review
and refers them to our on-site professional dental consultants. Based on the review of the claim and radiographs,
the dental consultant considers whether benefits are
payable and may identify the benefits payable for a costeffective alternative that meets the generally acceptable
standard of treatment of the dental community.
✓ Computer Voice Response System
We offer providers telephone access to dental benefit plan
information and eligibility information, eliminating the
need for identification cards and vouchers. Identification
cards are still provided when requested.
✓ Predetermination of Benefits
For major dental services, we offer employees the option
of finding out in advance the dental benefits that may be
covered on a proposed claim.
✓ List Billing Services
The employer will receive a monthly premium statement
showing the amount of premium due and providing a
list of insured employees and premium by coverage.
Small Business Center
Dental Insurance for 2-9 Lives
What’s Covered
Primary Coverage
Covered dental expenses fall into one of the following categories:1
Diagnostic & Preventive Services — Type A Expenses
◆ Oral examinations but not more than once every 6
months.
◆ Full mouth x-rays but not more than once every 5 years.
◆ Bitewing x-rays but not more than once every 6 months.
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— Replacing an existing immediate temporary full
denture by a new permanent full denture when the
existing denture cannot be made permanent, and
the permanent denture is installed within 12 months
after the existing denture was installed.
— 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.
◆ Scaling and polishing of teeth — oral prophylaxis —
but not more than once every 6 months.
◆ Inlays, onlays, crowns, laminates and gold foils, but no
more than once in a 10-year period for the same tooth
surface.
◆ Topical fluoride treatment once per calendar year for
dependent children under age 19.
◆ Replacement of crowns, but not more than once for the
same tooth in a 10-year period.
◆ Space maintainers for dependents under age 19.
◆ Periodontal maintenance where periodontal treatment
has been previously performed, but the total of covered
periodontal maintenance treatments and the number of
covered oral prophylaxes will not exceed four treatments
in a calendar year.
◆ Replacement of inlays or onlays, but not more than once
for the same tooth surface in a 10-year period.
◆ All repairs on dentures, crowns, inlays, onlays and bridgework.
Rates
Basic Services — Type B Expenses
◆ Fillings — amalgam or resin composite fillings.
◆ Extractions, except those for orthodontics.
◆ Oral surgery except procedures covered under any
medical plan.
◆ Administration of general anesthesia, when medically
necessary in connection with oral surgery.
◆ Emergency palliative treatment.
◆ Injections of antibiotic drugs.
For Plans 1 & 2
Initial rates are guaranteed for one year from the effective
date of coverage, as specified in the cost and benefit
summary.
For Plan 3
Initial rates are guaranteed for the first and second years of
coverage from the effective date of coverage, as specified in
the cost and benefit summary.
Eligibility
Major Services — Type C Expenses
Full-time Employees
◆ Endodontics — root canal treatment.
Only active full-time employees who work at least 30 hours
per week or active full-time salaried employees who work at
least 30 hours per week are eligible for coverage.
◆ Periodontal surgery.
◆ Those services needed to replace one or more natural
teeth lost while dental expense benefits are in effect for:
— Installation of fixed bridgework for the first time.
— Installation of a partial or full removable denture for
the first time.
— Replacing an existing removable denture or fixed
bridgework if it is needed because of the loss of one
or more natural teeth after denture or bridgework
was installed, or because the denture or bridgework
can no longer be used and was installed at least 10
years prior to its replacement.
1 The Reasonable and Customary charge is based on the lesser of (1) the dentist’s
actual charge, (2) the dentist’s usual charge for the same or similar services, or
(3) the usual charge of most dentists in the same geographic area for the same or
similar services as determined by MetLife.
Spouses and unmarried children of active insured fulltime employees are eligible dependents. Children are eligible to age 19, or 25 if enrolled as a full-time student in an
accredited secondary school.2
Retirees are not eligible for coverage.
2 Subject to state limitations.
Small Business Center
Dental Insurance for 2-9 Lives
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✗ Limitations on Prior Coverage
Minimum Participation
Requirements
The following guidelines will apply to all new business
quotes and to renewals and requests to amend coverage.
Contributory Plans
The employer’s contribution must equal at least 25% of the
cost of the insurance; employee participation requirements
are based on the participation table on the following page.
Dependent coverage may be written with no employer contributions. At least 75% of eligible dependents that are not waiving
coverage due to coverage elsewhere must be covered. In addition, at least 30% of all eligible dependents must be covered.
EMPLOYEE COVERAGE
Number Eligible
Minimum Number Insured
2
2
3
3
4
4
5
4
6
5
7
5
8
6
9
7
Available
Coinsurance
Plans
Coverage Limitations
Apply to Groups with:
• No prior dental
coverage
Available
Annual Maximum
Options
3
$1,000
• Prior dental coverage,
but no prior coverage
for major services
1 or 2
$1,000
• Prior dental coverage,
including major, with
$1,000 annual maximum
1 or 2
$1,000
• Prior dental coverage,
including major, with
$1,000 annual maximum
1 or 2
$1,500
✗ Generally Accepted Dental Standards
MetLife determines benefit payments for dental expenses under a MetLife group dental plan. Benefits will be
payable for a recommended dental service only if it is
classified as “necessary” by MetLife in terms of generally
accepted dental standards.
Exclusions
Non-contributory Plans
The employer pays 100% of the employee (or dependent)
premium, and all eligible employees (or dependents) must
be covered.
(The following expenses are not covered dental
expenses)
✗ Services or supplies…
– related to teeth lost before dental benefits began;
Limitations
– received by a covered person before dental expense
benefits became effective for that person;
✗ Coordination of Benefits
– that are covered by any worker’s compensation laws or
Our plans contain a “coordination of benefits” clause that
may reduce MetLife benefits based upon benefits
received from another group, employer or government
sponsored
plan. The benefits under a MetLife group dental plan and
any other plan providing benefits for covered dental services cannot exceed 100% of the total allowable expense.
✗ Late Entrants
Persons who request coverage more than 31 days after
their original eligibility date, or who were not covered
under the prior plan for which they were eligible, are
considered late entrants. Their coverage for diagnostic &
preventive services (Type A) will be available immediately; however, other services will be deferred until coverage
has been in effect for the applicable period of time set
forth below (subject to state restrictions):
– Basic Restorative Procedures (Fillings) 6 months
– Basic Procedures (All others)
12 months
– Major Services
24 months
occupational disease laws;
– that are covered by any employer’s liability laws;
– that an employer is required by law to furnish in whole
or in part;
– received through the medical department or similar
facility which is maintained by the covered person’s
employer;
– received by a covered person for which no charge would
have been made in the absence of dental expense benefits for that covered person;
– for which a covered person is not required to pay;
– that do not meet generally accepted dental standards,
(Continued)
Small Business Center
Dental Insurance for 2-9 Lives
Exclusions
(continued)
including experimental treatment;
– received as a result of dental disease, defect, or injury
due to an act of war, or warlike act in time of peace, that
occurs while the dental expense benefits for the covered
person are in effect;
– that are provided by any other plan that the employer
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Cancellation/Termination
Coverage is provided through employer participation in a
multiple employer trust (MET), and is subject to the terms
and provisions in the MET and Master Group Policy (Form
G.2130-S) sitused in the District of Columbia, with certificates
of insurance (Form G.23000) issued to each insured employee.
In any state validly exercising extraterritorial jurisdiction, the
plan will be modified to meet applicable laws.
(or an affiliate) contributes to or sponsors.
Coverage terminates:
✗ Services not performed by a licensed dentist except for
those of a licensed dental hygienist that 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; it is required for re-constructive surgery
that is incidental to or follows surgery that results from
a trauma, an infection or other disease of the involved
part; or is required for re-constructive surgery because
of a congenital disease or anomaly of a dependent child
that has resulted in a functional defect.
✗ Replacement of a lost, missing or stolen crown, bridge or
denture.
✗ Orthodontia, including repair or replacement of an
✗ When the employee’s full-time employment ceases;
✗ When the employee’s contributions cease (if such
contributions are required);
✗ Upon termination of the coverage by the employer, with
prior written notice to MetLife;
✗ When the employer’s required contributions cease;
✗ All benefits on account of a dependent will end on the
date that dependent ceases to be a dependent; or
✗ If the group insurance plan is discontinued by MetLife
for non-payment of premium or if participation requirements or minimum lives covered requirements are not
met.
orthodontic appliance.
✗ Adjustment of a denture or a bridgework which is made
within six months after it is installed by the same dentist
who installed it.
✗ Any duplicate appliance or prosthetic device.
✗ Use of materials or home health aids, to prevent decay,
such as toothpaste or fluoride gels, other than the topical
application of fluorides.
✗ Instruction for oral care such as hygiene or diet.
✗ Application of sealant material.
✗ Sterilization supplies.
✗ Services furnished by a family member.
✗ Periodontal splinting.
✗ Myofunctional therapy or correction of harmful habits.
✗ Implantology.
Note:
Your MetLife Small Business Center sales representative
can answer any questions about costs and details of
coverage. A full description of the benefits will be provided
in the certificate.
✗ Charges by a dentist for completing dental forms.
✗ Charges for broken appointments.
✗ Treatment of temporomandibular joint disorders.
Small Business Center
Metropolitan Life Insurance Company, New York, NY 10010
L02062JX4(exp0603)(xMD,NY,SD)MLIC-LD