How The Plans Work

The FlexSolutions Dental Plans are traditional dental plans in that you may obtain dental services from any qualified dental provider. However, you may be able to reduce your costs (and paperwork) by utilizing dentists who participate in each Plan's provider network, as explained under Choice of Providers.

There are no deductibles to meet—the Plans begin paying benefits with the first eligible expense that you incur.

There is an annual maximum benefit of $2,000 per covered person. Each January 1, a new $2,000 maximum will apply for services that you or a covered family member receive, even if you reached the maximum benefit amount in the prior year. Orthodontic treatment (which is available only to dependent children) is limited to $1,500 per individual, per lifetime. (See Who Is Eligible for a definition of dependent children.)

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Choice Of Providers

The HDS- and MetLife-administered Dental Plans allow you to use any qualified licensed dentist you choose. However, both Plans provide you with an option that can reduce your out-of-pocket costs (and usually eliminate the need for you to file a claim for benefits) as outlined below.

Provider Choice Under HDS

In Hawaii, 97% of the licensed dentists are HDS "member dentists." If you visit one of these dentists, the dentist will receive payment directly from HDS (see Benefit Payments for more details). You will only need to pay the applicable copayment percentage for any covered benefits.

In contrast, if you visit a non-member dentist, you will need to pay...

  • The applicable copayment percentage for any covered benefits, plus

  • Any additional costs for fees the dentist charges that exceed the HDS Table of Allowances for that benefit.

To receive benefits when you use non-member dentists, you will usually need to pay the dentist in full at the time you receive the services, then file a claim with HDS for reimbursement.

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Provider Choice Under MetLife 

The MetLife-administered Dental Plans feature a "preferred provider" option (PPO). If you use dentists who are members of MetLife's PPO network, your out-of-pocket costs will be reduced. Here's how it works...

  • When you use network dentists, you pay only the applicable percentage of the negotiated charge—the amount the dentist, under its agreement with MetLife, has agreed to charge plan participants—instead of the otherwise eligible charge; thus,

  • Since negotiated charges are generally less than eligible charges, your out-of-pocket expense is less.

To find a PPO dentist, or to determine whether your existing dentist participates in the MetLife PPO network, call 800-474-7371. MetLife's telephone-based system will prompt you to enter your Social Security Number and the zip code of the area for which you want a directory. You can also conduct an on-line provider search by visiting the MetLife Website at www.metlife.com/dental.

You may also use a non-network dentist. In this case, the Plan will continue to pay its share of the eligible charges. However, you will need to pay...

  • The applicable copayment percentage for the covered benefit, plus

  • Any amount that exceeds the eligible charge for that benefit.

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Benefit Payments

When you obtain dental services, you (or your dentist) must file a claim for reimbursement. Claim forms are available from your local Human Resources representative or on-line via the Company intranet. Claim forms may also be available at your dentist's office. Be sure to complete the form as instructed and send it to the address indicated on the form.

If you visit a dentist who is a member of the HDS or MetLife network, your claim will usually be filed by the dentist.

Benefit payments are based on Usual, Customary and Reasonable charges for HDS and Reasonable and Customary charges for MetLife.

Any amount that exceeds the UCR amount is your responsibility, unless you have visited an HDS-member or MetLife PPO dentist.

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Pre-Authorization Of Benefits

Because dental services can sometimes be costly, both Dental Plans feature a "pre-authorization of benefits" program. If you anticipate that the recommended dental services are likely to cost more than $300 (MetLife) or $400 (HDS), you should ask your dentist to file a pre-authorization of benefits with HDS or MetLife, as applicable. Most dentists are familiar with this process and will cooperate.

Note that this program may also be referred to as "predetermination of benefits."

To obtain a pre-authorization of benefits...

  • Ask your dentist to notify the Claims Administrator of what work needs to be done, listing the services and charges on the claim form, and submitting it to the Claims Administrator. (This is the "treatment plan.")

  • The Claims Administrator will review the treatment plan and inform your dentist how much the Plan will pay.

  • You should then discuss the treatment with your dentist before any work begins.

The pre-authorization will remain on file with the Claims Administrator for 90 days. In general, if you do not obtain treatment within 90 days, you (and your dentist) need to resubmit the treatment plan for pre-authorization. However, under the MetLife-administered Plan, the pre-authorization will be honored for up to two years if you retain a copy and submit it with your claim.

If your dentist changes the treatment plan after obtaining a pre-authorization of benefits, the actual benefit payment amount may change. If there is a major change in your treatment, be sure your dentist submits a new treatment plan to the Claims Administrator.

If you do not obtain a pre-authorization of benefits, the benefit amount payable will be based on the information the Claims Administrator receives regarding the treatment.

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Alternative Procedures

The list of eligible expenses under the Dental Plans is provided under What The Plans Cover. However, you should know that there is often more than one method dentists use to treat a dental problem. Different materials or procedures may be used to correct the same problem—for example, a tooth may be repaired with an amalgam filling, or it could be repaired with a more expensive cap (crown) or gold filling.

The Dental Plans will consider services and/or supplies as eligible expenses only if they are the least-expensive options that are appropriate and meet acceptable dental standards.

Of course, you and your dentist have the right to select a more expensive treatment. If you do, you must pay the difference between the actual charges and those that are considered eligible charges. This provision is another reason you should always complete a pre-authorization of benefits before starting any dental treatment that is expected to exceed $300 (MetLife) or $400 (HDS).

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