About The Dental Plans

Introduction

FlexSolutions offers three dental plan options, regardless of where you live or work.* Under each option, you and your covered dependents are eligible to receive a wide range of dental services, as explained in the sections below.

* Employees in Guam receive dental coverage through a dental plan not described here.

Each of the options pays the entire cost of eligible diagnostic, preventive and certain therapeutic care expenses, such as routine exams and cleanings. Then, for other eligible expenses...

  • Option 1 pays 50%

  • Option 2 pays 65%

  • Option 3 pays 80%

Note, however, that depending on the plus any amounts that exceed the amount the Plan will pay. For details, see Choice of Providers.

The Dental Plans are administered by...

  • Hawaii Dental Service (HDS) in Hawaii, and

  • MetLife on the Mainland.

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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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What The Plans Cover

The benefits provided under the Dental Plans are intended to cover treatment that is customarily provided by dentists throughout the country to prevent and eliminate oral disease, and to repair or replace damaged or missing teeth. As noted under Benefit Payments , benefits for the Dental Plans are generally based on eligible charges for the services and supplies listed below.

If you use dentists who are members of the HDS or MetLife networks, these dentists agree to charge a certain amount; you are only responsible for your percentage share of this amount (and any applicable tax), not for any amounts that exceed the agreed amount.*

*The "agreed" amount is referred to as the "UCR" amount under the HDS-administered Plans, and the "negotiated" amount under the MetLife-administered Plans.

Should you use a non-network dentist and the dentist's charges exceed the agreed amount, you will be required to pay the difference.

Remember, too, that alternative procedures as explained previously can affect how much the Plan will pay.

Lastly, you should know that while your dentist may recommend a particular dental service, this does not mean that...

  • The dental service will be deemed necessary under the provisions of the Dental Plan, or

  • Benefits will be paid for the service.

When determining benefit payments, the Claims Administrator will make a decision as to whether the dental service is necessary based on generally accepted dental services and is an eligible service with regard to Plan benefits.

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Preventive, Diagnostic And Certain Therapeutic Services

All three Dental Plan options pay 100% of the eligible charges for preventive, diagnostic and therapeutic services as described below:

Preventive Services And Supplies

  • Cleaning and scaling of teeth (oral prophylaxis) twice each calendar year.

  • Sealant material applied to a dependent child's* permanent molar tooth; this benefit, which is covered only under the MetLife-administered Plans for children up to age 16, is limited to two applications per tooth per lifetime.

  • Fluoride treatments for a dependent child* through age 17 (HDS) or age 18 (MetLife) once each calendar year.

  • Space maintainers and their fitting for a dependent child* through age 17 (HDS) or age 18 (MetLife). Space maintainers are appliances used to keep teeth from moving into the space remaining after a tooth is pulled or lost.

* For the purposes of these benefits, a child is one that meets the definition of child as outlined under Who Is Eligible.

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Diagnostic Services And Supplies

  • Oral exams; provided once each calendar year under HDS and twice each calendar year under MetLife;

  • X-rays and laboratory tests needed to diagnose a dental problem (as required);

  • Full mouth X-rays once every three years;

  • Bitewing X-rays available twice each calendar year.

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Therapeutic Services And Supplies

  • Emergency treatment for dental pain when no other treatment but x-rays is given; if other treatment is given, payment at this benefit level (i.e., 100%) will be made only for the palliative treatment—any other treatment will be paid at the applicable benefit level (i.e., 50%, 65% or 80%).

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General Services

All three Dental Plan options provide benefits for general or "basic" dental services. The actual percentage amount paid is based on the option you elected through FlexSolutions: 50% under Option 1, 65% under Option 2 and 80% under Option 3.

Therapeutic Services And Supplies

  • Pulling teeth (extractions) and cutting procedures in the mouth (oral surgery); extra charges for removing stitches and for exams after surgery are not covered.

  • Root canal work (endodontic treatment).

  • Treatment of gums and mouth tissues (periodontic treatment).

  • General anesthetics for oral surgery (local anesthetics are considered to be included in the treatment charges, so extra charges for local anesthetics are not covered).

  • Injections of antibiotic drugs (covered under the MetLife-administered Plan only).

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Restorative Services

  • Silver (amalgam), silicate, plastic, porcelain, and composite fillings. Note: If a tooth can be replaced by a less expensive method, then only that charge will be covered. (See Alternative Procedures for more details.)

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Prosthetic Services And Supplies (Repairs And Rebasing)

  • Repairs to broken crowns, inlays, bridgework, and dentures; however, this does not include adjustments made to new dentures or bridgework during the first six months after they are installed. These charges are considered to be included in the cost of the new denture or bridgework; extra charges are not covered.

  • Rebasing or relining dentures; this is a covered benefit if provided two years after the insertion of a denture (HDS) and not more than once in a 36-month period (MetLife).

  • Adding teeth to fixed bridgework or partial dentures to replace missing natural teeth.

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Major Services

All three Dental Plan options provide benefits for major dental services. The actual percentage amount paid is based on the option you elected through FlexSolutions: 50% under Option 1, 65% under Option 2 and 80% under Option 3.

Major services include the following:

Restorative Services And Supplies

  • Crowns and fillings* to repair a tooth broken down by decay or fracture, as long as:

    • the tooth cannot be repaired with a less-expensive type of filling; if the tooth can be repaired by a less-expensive method, then only that charge will be covered; and

    • the old crown or filling* is at least five years old.

  • Inlays and onlays, but not more than one such restoration to the same tooth within five years of the prior restoration.

* Under the HDS-administered Plan, benefits are limited to crowns and gold restorations.

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Prosthetic Services And Supplies (Dentures And Fixed Bridges)

  • Full or partial dentures and fixed bridgework to replace missing natural teeth; and

  • Full or partial dentures and fixed bridgework to replace an existing denture or bridge that cannot be made serviceable; if the existing denture or bridge was inserted while the individual was covered under this Plan, the existing denture or bridge must be over seven years old.

Note that charges for special techniques or precision attachments are not covered nor are any charges for any special work that you ask to have done on a standard denture. Also, charges made for adjustments to new dentures or bridgework during the first six months after they are inserted are not covered as these are considered to be included in the new fee for the denture or bridgework.

A permanent denture may replace an existing temporary one. However, in this case, charges for both are limited to the charge for the permanent one.

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Orthodontic Services

All three Dental Plan options provide benefits for orthodontic services provided to covered dependent children. As with general and major services, the actual percentage amount paid is based on the option you elected through FlexSolutions: 50% under Option 1, 65% under Option 2 and 80% under Option 3. These benefits are limited to $1,500 per the covered individual's lifetime.

Eligible charges for orthodontic services include the customary charges made by a dentist for straightening teeth. This includes...

  • Diagnostic procedures, and

  • Appliances to realign the teeth.

Note that necessary space maintainers and teeth extractions are covered under the other portions of this Plan, not under the orthodontic benefit.

As with other dental charges, the Claims Administrator will compare the charge for orthodontic treatment with the charges for comparable treatment made by other dentists in the area. For details, see How The Plans Work.

Orthodontic services are not covered if...

Limitations Of Orthodontic Coverage

  • Orthodontic services are not covered if services were started prior to the date the patient became eligible under this Plan.

  • If a patient's eligibility ends prior to the completion of the orthodontic treatment, payments will not continue.

  • If A&B terminates orthodontic benefits from this Plan, coverage will end on the last day of the month that the change occurred. 

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Payment Sequence

Benefit payments for orthodontic treatment will be made in installments; the exact payment provisions will vary based on the determination of the applicable Claims Administrator (HDS in Hawaii and MetLife on the Mainland).

The following rules apply to benefit payments for orthodontic services...

  • The individual receiving the treatment must be covered under this Plan on the first day of the period in order to receive payment for that period.

  • If the orthodontic treatment is stopped for any reason before it is complete, benefits will be paid for only those services and supplies actually received.

  • Any benefits for orthodontic treatment stop when coverage for the individual receiving the treatment ends under this Plan—no benefits are payable for charges made after coverage ends.

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What The Plans Do Not Cover

The following services are not covered under the FlexSolutions Dental Plans. Keep in mind that covered services may be subject to certain restrictions as noted in the applicable descriptions of covered services above.

  • Acupuncture therapy.

  • Adjustment of a denture or a bridgework that is made within six months after insertion by the same dentist who inserted it.

  • Any duplicate appliance or prosthetic device, except partial dentures or bridgework that cannot be made serviceable.

  • Charges for or in connection with services or supplies that are, as determined by the Claims Administrator, to be experimental or investigational. A drug, device, procedure, or treatment will be determined to be experimental or investigational, and therefore not covered, if:

    • there are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury involved;

    • approval is required by the FDA, and FDA approval has not been granted for marketing;

    • a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational or for research purposes; or

    • the written protocol or protocols used by the treating facility or the protocol or protocols of any other facility studying substantially the same drug, device, procedure, or treatment, or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure, or treatment states that it is experimental, investigational or for research purposes.

  • Charges for broken appointments or for completing dental forms.

  • Charges for crowns and fillings not specified as covered under the Plan.

  • Cosmetic surgery, treatment, services, or supplies; however such items will be covered if required for the treatment or correction of a congenital defect of a newborn dependent child eligible for benefits under this Plan.

  • Facings or veneers on molar crowns or molar false teeth.

  • Implantology.

  • Initial installation of a denture or bridgework to replace one or more natural teeth lost before the individual became covered under this Plan. This exclusion does not apply under the HDS-administered Dental Plans.

  • Instructions for oral care, such as hygiene or diet.

  • Myofunctional therapy or correction of harmful habits.

  • Periodontal splinting.

  • Prescription drugs prescribed by a dentist. However, individuals covered under a FlexSolutions Medical Plan may receive coverage for drugs prescribed by a dentist under the applicable medical plan's prescription drug benefit program. For information regarding the prescription drug benefits, refer to the prescription drug information provided within About The HMSA Medical Plans, About The CIGNA Medical Plans, or About The Kaiser HMO as applicable.

  • Procedures, appliances, restorations, or replacement of structure loss from caries (decay), unless necessary to alter, restore or maintain occlusion. Such procedures include, but are not limited to, increasing vertical dimension, equilibration, periodontal splinting, restoration of tooth structure lost from attrition, restorations for tooth malalignment, and gnathological recordings.

  • Repair or replacement of an orthodontic appliance.

  • Replacement of a lost, missing or stolen crown, bridge or denture.

  • Routine exams or other preventive services and supplies, except those as specifically stated as covered under What The Plans Cover.

  • Services or supplies received by an individual before he or she becomes covered under this Plan.

  • Services not performed by a dentist; however, certain services (namely cleaning and scaling of teeth, and fluoride treatments) provided by a licensed dental hygienist are covered when supervised and billed by a dentist.

  • Services or supplies that are covered by any workers' compensation, occupational disease or employers' liability laws; or that any employer is required by law to furnish, in whole or in part. Also, any services or supplies received through a medical department or similar facility maintained by the covered individual's employer, or that are provided as a benefit under any other plan sponsored by the Company.

  • Services or supplies received by a covered individual for which no charge would have been made in the absence of this coverage or for which the covered individual is not required to pay.

  • Services or supplies deemed experimental in terms of generally accepted dental standards.

  • Services or supplies received as a result of a dental disease, defect or injury due to an act of war, or a warlike act in time of peace.

  • Services or supplies furnished by a family member.

  • Sterilization supplies.

  • Treatment for TMJ or skeletal disharmonies of the jaw.

  • Use of materials to prevent decay (other than fluorides and sealant material for a dependent child subject to the age restrictions outlined under What The Plans Cover). Note that sealants are not covered under HDS.

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If Your Dental Benefits End

In general, you may not receive benefits for any dental expenses incurred after your coverage ends, even if you have already obtained a pre-authorization of benefits. However, benefits may be paid for certain dental expenses incurred after your coverage ends, depending on the circumstances. Contact HDS or MetLife directly for more details.

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The information in this handbook is for summary purposes only. If any discrepancy exists between the information in this Benefits Handbook and the official plan documents, the official plan documents will govern. For additional details, please see Important Information. Updated: 03/07/2011
© A&B.