Loading...
HomeMy WebLinkAboutPDP2✓ MetLife is the largest commercial dental carrier in the United States' 1 The largest PPO in the Industry based on enrolled lives ✓ Dental benefit administrator for 46 of the Fortune® 100 companies2 ✓ Distinguished commitment to quality initiatives and service excellence Islet Life City of Miami Dental - Preferred Dentist Pro • ram (PDP) Insured Estimated Number of Eligible Employees Eligible Class Eligible Dependent Eli ' ibili Waitin • Period Basis of Reimbursement Type A'. Preventive Type B — Basic Type C -- Ma,or Type 0— ortiodontia — Child and Adult coverage Individual Deductible (Annual) . Family Deductible (Annual) Deductible Applies To Calendar Year:?Maximum Lifetime Orthodontic Maximurn Lifetime TMJ Maxllmulrl Employee Only Empooeee + Family Estimated Annual Premium Rate Guarantee Period 149 Plan 1 - Executives Up to age 25, 25 if full-time student Negotiated PDP fee 100% 80% 80% 80% $50.00 $150.00 Type B & C $1,500.00 $1,500.00 $750 Rate Information Rate Year 1 - $50.17 Year 2 - $53.93 Year 3-$57.70 90th percentile of Reasonable & Customary (R&C) 100% 80% 80% 80% $50.00 $150.00 Type B & C $1,500.00 $1,500.00 $750 Assumed articlpatiion 61 Employees Year 1 - $153.35 Year 2 - $164.85 Year 3 - $178.35 88 Employees $198,662.04 01 /01 /2005-12/31 /2007 Cost & Benefit Summary Dental - PDP Insured P0186884 5 Plan 1 - Executives Quote Generated by MetLife on 06/11/2004 G23000 i MetLife' Plan and Underwriting Plan Features Assumptions Effective Date 01/01/2005 MetLife Employee Benefits Website: www.metlife.com/mybenefits • Eligibility and Plan Design • Claims Status and History • PDP Network Directory search / directions • Dental EOBs via e-mail service • Claim forms and other program information • Consolidated service site with other products (as applicable) 01/01/2005 Employer On -Line Capabilities via MetLink Quote Valid Until Employer Contributions • Employee coverage • Dependent coverage Financial Arrangement Commissions • Billing • Eligibility • Claims • Claims reporting Customer Service Voice Response capabilities • Spanish language capabilities 100% • Spoken or "Fast -Fax" fax -on -demand service for eligibility, plan design, claim status / history, PDP network directories (by fax or mail) and claim forms (fax 0% only) available to employees and providers Non- Charges for all services are based on the PDP fee if the Retrospectively services are performed by a participating PDP general Experience dentist or specialist regardless of whether the plan covers Rated (Non- those services (e.g. Orthodontia, cosmetics, etc.) Par) None Minimum Participation Requirement Lead Time Requirement 93% 30 calendar days from notification of sale to effective date Deviations (if any) appear on following page Administering dental benefits for 19.8 million people. MetLife Market Research, January, 2003. 2 Fortune Magazine, May 2003. Cost & Benefit Summary Dental - PDP insured P0166864 5 Plan 1 - Executives Quote Generated by MetLife on 06/11/2004 G23000 2 MetLife' Deviations Based on our understanding of the provisions outlined in the request for proposal, and for the purposes of expediting this quote, we have attempted to follow the required arrangements and bid specifications as closely as possible - with the exception of the following deviations. Please note that deviations listed below may be subject to change to accommodate the final plan design and/or administrative procedures. In the event that such a change does occur, it would be in accordance with the terms of this proposal, MetLife standard underwriting practices, and applicable legislative and regulatory requirements. • Please see the enclosed procedure allocations, frequencies, limitations, and exclusions. These procedures will override any current provisions. a MetLife's standard exclusions will apply. o This quote assumes participation of 93%. If this changes by more than 10%, we reserve the right to adjust rates and/or alter benefit provisions. • MetLife's standard late entrant period will apply. It is not a duplication of the existing provision. Eligibility / Enrollment Only individuals residing in the United States are eligible for coverage. This quote assumes the use of standard MetLife enrollment forms when eligibility data is submitted via paper documents. Enrollment Maintenance Eligibility will be maintained for employees and dependents. Late Enrollment Employees who wish to enroll after electing no coverage at their initial enrollment period must wait until the first enrollment period after a twelve month wait for all services. Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0166864 5 Plan 2 - All Non -executives Quote Generated by MetLife on 06/11/2004 G23000 3 MetLif i Plan Design Allocation of Services : Comprehensive Plans Type A Type B Type C Type D Preventive Basic Major Orthodontia • Oral Exams • Fillings • Inlays/Onlays • Orthodontic • Full Mouth X-rays • Repairs • All Other Crowns Diagnostics • Bitewing X-rays • Pulp Capping/ pulpal • Dentures • Orthodontic • Periapicals and other therapy • Bridges Treatment X-rays • Endodontics/Root • Temporomandibular • Labs and other tests Canal Joint Disorder (TMJ) • • Prophylaxis/Cleaning Fluoride Treatments • Periodontal maintenance • Sealants • Periodontics • Space Maintainers • Rebases/Relines • Palliative Care • Simple Extractions • Surgical Extractions • Oral Surgery • General Anesthesia • Consultations • Prefabricated Stainless Steel and Resin Crowns Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0166864 5 Plan 2 - All Non -executives Quote Generated by MetLife on 06/11/2004 G23000 4 MetLife r Limitations / Exclusions I Provisions on Dental Services Type A (Preventive) • 2 oral exams per calendar year • 1 fluoride treatment in 12 consecutive months for dependent child to age 19 • 2 cleanings (oral prophylaxis) per calendar year • Full mouth and panorex x-rays: once per 60 months • Bitewing x-rays: once per calendar year for adults; once in six consecutive months for children • Space maintainers: limitation of one space maintainer per lifetime per area for premature loss of primary teeth for dependent children to age 19 • Sealants: limitation of one application of sealant material for each non -restored permanent 1st and 2nd molar tooth of a dependent child to age 14, once every 60 months Type B (Basic) • Relines and rebases to dentures are limited to one per 36 months (minimum is 6 months after initial installation) • Adjustment of dentures (minimum is 6 months after initial installation) • Periodontal maintenance where periodontal treatment (including scaling, root planing, and periodontal surgery such as gingivectomy, gingivoplasty, gingival curettage and osseous surgery) has been performed. Periodontal maintenance is limited to 4 times in any year less the number of teeth cleanings received during such 12-month period. • Periodontal scaling and root planing, but not more than once per quadrant in any 24-month period • Periodontal surgery, including gingivectomy or gingivoplasty, gingival curettage, osseous surgery, bone replacement graft and guided tissue regeneration once per quadrant every 36 months • Root canal treatment is limited to once per tooth in a 24-month period • Consultations are limited to twice in 12 consecutive months • Prefabricated stainless steel and resin crown replacement: 5 years Type C (Major) • Initial installation of fixed bridgework • Initial installation of partial or full removable dentures • Initial installation of crowns, inlays and onlays (cast restorations): once in 60 consecutive months • Dentures and bridgework replacement: 5 years • Immediate denture replacement: 12 months • All other crown replacement: 5 years Type D (Orthodontia) Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0166864 5 Plan 2 - All Non -executives Quote Generated by MetLife on 06/11/2004 G23000 5 MetLife • All dental procedures performed in connection with Orthodontic treatment are payable as Orthodontia • Initial payment due upon installation of the Orthodontic appliance; repetitive payments for the Orthodontic adjustments will be made quarterly at the end of the quarter based on the Orthodontic Lifetime Maximum • Benefits end at cancellation Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0166864 5 Plan 2 - All Non -executives Quote Generated by MetLife on 06/11/2004 G23000 6 MetLife. Exclusions : charges incurred for the following: • Implantology • Harmful Habit Appliance • Services or supplies received before dental expense benefits start for that person • Services not performed by a Dentist except for those of a licensed dental hygienist for scaling and polishing of teeth, fluoride treatments • Cosmetic surgery, treatment of supplies, unless required for the treatment or correction of a congenital defect of a newborn Dependent child • Replacement of a lost, missing or stolen crown, bridge or denture • Services or supplies which are covered by any workers' compensation laws or occupational disease laws • Services or supplies which are covered by any employers' liability laws • Services or supplies which any employer is required by law to furnish in whole or in part • Services or supplies received through a medical department or similar facility which is maintained by the Covered Person's employer • Repair or replacement of an orthodontic appliance • Services or supplies for which no charge would have been made in the absence of Dental Expense Benefits • Services or supplies for which a Covered Person is not required to pay • Services or supplies which are deemed experimental in terms of generally accepted dental standards • Services or supplies received as a result of dental disease, defect or injury due to an act of war, or a warlike act in time of peace • Adjustment of a denture or a bridgework which is made within 6 months after installation by the same dentist who installed it • Any duplicate appliance or prosthetic device • Use of material or home health aids to prevent decay, such as toothpaste or fluoride gels, other than the topical application of fluoride provided in a dental office • Instruction for oral care such as hygiene or diet • Periodontal splinting • Temporary or provisional restorations • Temporary or provisional appliances • Services or supplies to the extent that benefits are otherwise provided under the plan or under any other plan which the Employer contributes to or sponsors • Appliances or treatment for bruxism (grinding teeth) including but not limited to occlusal guards and night guards • Initial installation of a denture or bridgework to replace one or more natural teeth lost before • Charges for broken appointments • Dental Expense Benefits started or as a replacement for congenitally missing natural teeth • Charges by the Dentist for completing dental forms • Sterilization supplies or charges • Services or supplies furnished by a family member Cost & Benefit Summary Dental - POP Copay Voluntary Insured P0186864 5 Plan 2 - All Non -executives Quote Generated by MetLlfe on 06/11/2004 G23000 MetLife Other Provisions: • Coordination of benefits follows the NAIC model • Expense period is on a calendar year basis • Overpayments are deducted from future claims on any family member • Claims history is required for all lifetime maximums, as well as for annual deductibles and annual maximums with effective dates other than January 1st. MetLife must receive history by the effective date of the proposed plan. If history is not received by the effective date, orthodontia claims will not be processed and non -orthodontia claims will be processed assuming that no annual deductibles have been met. • Fourth quarter deductible carryover is excluded unless duplicating a current plan provision. • Family deductible on Family/Accumulative basis applies • Explanation of Benefits are sent to the employee and the provider Cost & Benefit Summary Dental - POP Copay Voluntary Insured P0188864 5 Plan 2 - All Non -executives Quote Generated by MetLife on 08/11/2004 023000 8 MetLife Biking Claim Of ice Handling Network Locations & Fees Printing Coat Options Renewal Notification Plan and Underwriting Assumptions Premium is due on the first day of each month. The grace period is 31 days. Lapse logic will apply to this case. Lapse logic processing means if premium is not received by the end of the grace period, MetLife reserves the right to cancel the entire policy for non-payment of premium. This quote assumes self -billing through the use of MetLink, a MetLife Internet based benefits management system. MetLife will provide up to 10 claim and/or premium separations at no additional charge. If additional separations are needed, there will be an additional charge. Eligibility Adjudication — MetLife Claim Certification & Adjudication — MetLife Claim Office — MetLife This quote assumes the use of standard MetLife claim forms. The PDP quote assumes that PDP will be offered in all locations. The Network Access Fee has been included in the quoted Insured Rates. This quote includes the cost of printing standard MetLife booklets and certificate material, standard MetLife claim forms and standard MetLife enrollment kits and educational material. 80 days in advance Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0188884 5 Plan 2 - All Non -executives Quote Generated by MetLife on 08/11/2004 G23000 9 MetLife Rate Change MetLife reserves the right to change its rates at any time (not withstanding any rate guarantee), before the effective date of the policy, and / or after the contract is issued on the first day of each policy period for any of the following reasons: • The composition of the group has changed 10% or more from its composition when quoted, including but not limited to, a change in the number of eligible employees or dependents, a change in the number of participating employees or dependents, or a change in the distribution of employees between available plan options • The financial arrangement on any part of the package has changed • Any of the coverages are cancelled or not issued • Any of the plan designs are changed, including but not limited to, changes in covered services, co-insurance, deductibles, and frequency limits • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the plan • If there is a difference in the actual demographic distribution of insured employees from the time of quote We also reserve the right to change our rates, notwithstanding any fee guarantee, on any fee due date following a change of 10% or more in the number of employees insured for personal insurance and dependent insurance. Situs This quote assumes the client is sitused in Florida. System Compatibility If MetLife is requested to duplicate contractual provisions from the prior carrier, such provisions must be compatible with MetLife's claim auto -adjudication standards. MetLife's standard contractual provisions will apply should provisions be incompatible with these standards, or additional charges may apply. Cancellation / - Termination This coverage may be canceled by either party according to the provisions contained within the contract. Coverage is provided under Policy Form Number GPNP99. Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0166884 5 Plan 2 - All Non -executives Quote Generated by Mettle on 06/11/2004 G23000 10 MetLife' Non -Covered Services Plan Features Participating PDP dentists agree to accept as payment in full, the fees in the table of maximum allowable charges for non -covered services such as cosmetics and Orthodontia. Orthodontics Participating PDP dentists agree to accept as payment in full the MetLife negotiated fee for orthodontic treatment. With the possible exception of complex orthodontia, dentists have agreed not to charge patients over this amount even if not a covered benefit. In certain cases of greater complexity, as reviewed by MetLife, MetLife may determine that a higher fee can be charged by the participating PDP dentist. Free Oral Exam . Participating PDP dentists may only charge for one periodic oral exam (ADA code 00120) per patient per calendar year, resulting in 2-3% annual claims savings for the employer. Out -of -Network Out -of -Network Reasonable & Customary calculated at 90th percentile. Account Management Client Support Dedicated Account team includes Account Specialist and Customer Advocate. Online Employer Services MetLink®Online Benefit Administration platform provided free of charge: Includes e-billing, reporting, eligibility, status change and other transactions and information. Customer Reports Wide range of standard and system generated customer reports available. Other Services If requested, MetLife will provide plan design consultation to help ensure your plan design most effectively meets your goals. Customer Service Customer Service MetLife's multi -channel approach to customer service allows employees to access information in the manner that they choose, at the "time of need" through Internet, phone, Fax, or access to trained Customer Service consultants. Internet uwww.metlife.com/MyBenefits, Online Information and Transaction website assists to help employees better understand and use their plan. Includes Eligibility / Plan Design, Claim status/history, Network directories, claim forms and other program information. Online EOB's with e-mail notification of processed claim service is also available. MetDental.com, Online Information and Transaction website for providers promotes information exchange and education, generally while patients are in the dentist's office through real-time eligibility, plan design, claims status, and benefit estimates. Online claim submission, EOBs and EFT functions decrease claim processing time and payment cycles reducing inquiries increasing Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0186864 5 Plan 2 - All Non -executives Quote Generated by MetLife on 06/11/2004 G23000 11 MetLife Fax Service Phone Service Claims Statistics program satisfaction. "Fast Fax" fax -on -demand service for eligibility, plan design, claim status/history, PDP network directories, and claim forms. For dentists without office Internet access, eligibility, plan design, claims status/history, free claim submission and real-time benefit estimates are available by Fax while the patient is still in the office. Toll -free Interactive Voice Response Unit provides immediate access to frequently sought information without the need to speak with Customer Response Consultants: Includes eligibility, plan benefits, claims status, PDP dentist directory orders, claim forms and FAX -ON -DEMAND function. For more complex inquiries, Customer Response Consultants are available toll - free 8 a.m. to 11 p.m. Monday through Thursday and 8 a.m. to 8 p.m. Fri. ET Claims • Over 28 million claims processed in 2002 with 99.86% payment accuracy • Over 85% of claims processed in 5 days or less • Over 96.5% of claims processed in 10 days or less • 80% auto -adjudication rate (claims processed without human intervention) • 5% of claims subject to MetLife claim review procedures Claims Office' Single submission address for all claims and correspondence Communications Support Enrollment ;/ Communisation • Complete employee enrollment kit including program and plan design descriptions and other information bulk -shipped to your location(s) • Program awareness, promotion and education materials available • Electronics materials available (PD / awareness / education e-mail) Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0168864 5 Plan 2 - All Non -executives Quote Generated by MetLife on 06/11/2004 G23000 12 MetLife PDP • Network Freedom of Choice Full Freedom -of -choice program allows employees to visit any dentist at any time without lock -ins or specialist referrals. Access Growing network of over 60,000 participating dentists have agreed to accept scheduled fees for services as payment in full, typically resulting in charges 10- 30% below community average charges. Credentialing PDP Dentists must pass strict up front and ongoing credentialing and utilization review to remain in the network. Quality Initiatives MetLife's industry -recognized Quality Initiatives Program promotes education and communication between employer, dentist and carrier. Metropolitan Life Insurance Company New York, New York 10010 L02026GRX(exp0504)MLIC-LD Cost & Benefit Summary Dental - PDP Copay Voluntary Insured P0166804 5 Plan 2 - All Non -executives Quote Generated by MetLife on 08/11/2004 G23000 13