Ameritas Dental Plan

Transcription

1 Ameritas Dental Plan Effective Date: July 1, 2015 Dental Plan Summary Coinsurance In Network Out of Network Type 1- Preventive 100% 100% Type 2 - Basic 80% 80% Type 3 - Major 50% 50% Deductible $0 (Waived) when member visits a network provider for covered procedures 3 Family Maximum $25 / Calendar Year Type 2 & 3 Waived Type 1 3 Family Maximum Maximum (per person) $1,500 per calendar year $1,500 per calendar year Allowance Maximum Allowable Charge 90th U&C Waiting Period None None Orthodontia Summary - Adult and Child Coverage In Network Out of Network Allowance Discounted Fee U&C Coinsurance 50% 50% Lifetime Maximum (per person) $1,000 $1,000 Waiting Period None None Eligible Employees You are eligible for insurance if you are a full-time active employee working at least 30 hours per week. Eligible Dependents Provides Coverage On: Your Spouse Children up to age 26 Page 22

2 Sample Procedure Listing (Current Dental Terminology American Dental Association.) In & Out of Network Type 1 - Preventive Type 2 - Basic Type 3 - Major Routine Exam (2 per benefit period) Bitewing X-rays (2 per benefit period) Sealants (age 16 and under) Restorative Amalgams Onlays Crowns (1 in 5 years per tooth) Full Mouth / Panoramic Restorative Composites Crown Repair X-rays (1 in 3 years) Endodontics (surgical & nonsurgical) Periapical X-rays Denture Repair Periodontics (surgical & nonsurgical) Cleaning (2 per benefit period) Simple Extractions Prosthodontics (fixed bridge; removable Fluoride for Children 18 and Complex Extractions complete/partial dentures) (1 in 5 years) under (1 per benefit period) Space Maintainers Anesthesia PPO Information To find a provider, visit ameritasgroup.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose PPO Dental Network. Pretreatment While we don t require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it s best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We ll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won t be any surprises once the work has been completed. Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered. Page 23

3 Ameritas Information We re Here to Help! This plan was designed specifically for the associates of Carter County Government. At Ameritas Group, we do more than provide coverage - we make sure there s always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: For plan information any time, access our automated voice response system or go online to ameritasgroup.com/ member. Dental Rewards This dental plan includes a valuable feature that allows qualifying plan members to carryover part of their unused annual maximum. A member earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. In addition, a person earning dental rewards who submits a claim for services received through the dental PPO network earns an extra reward, called the PPO Bonus. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan member doesn t submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year. Benefit Threshold $750 Annual Carryover Amount $250 Annual PPO Bonus $150 Maximum Carryover $1,000 Dental benefits received for the year cannot exceed this amount Dental Rewards amount is added to the following year s maximum Additional bonus is earned if the member sees a PPO provider Maximum possible accumulation for Dental Rewards & PPO Bonus combined Commonly Asked Questions Do I have to see an Ameritas PPO Provider? No, employees and their covered dependents may utilize any licensed dental provider they choose. Please note, the only difference is the deductible is waived for all services whenever a PPO provider is used. Page 24

4 Why would I use an Ameritas PPO Provider? By using a PPO Provider: A Participating Provider is a dentist who has entered into an agreement to provide services to insured members of Ameritas plans for a specific fee. Any insured member who chooses to go to a PPO provider will receive this discount fee for procedures performed by that provider. As part of their contractual agreement with Ameritas, the providers cannot back bill the patient for the difference the dentist normal charges and the discounted fees that the dentist agreed to charge as an Ameritas provider. PPO providers are required to file the claim for the patient PPO providers are required to wait for reimbursement from Ameritas before billing the patient for any balances owed for deductibles, coinsurance, any amount exceeding the annual maximum benefit, etc. Bi-Weekly Rates Employee Only (EE) $0.00 EE + Family $20.34 For Claims/Customer Service Questions Contact Ameritas at: or wwwameritasgroupcom This insurance is underwritten by Ameritas Life Insurance Corp. This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator. Page 25

5 Carter County Government Plan Design Summary Hearing Care Summary Proposed Effective Date: 1/1/2015 Plan 1: SoundCare SM Coinsurance Annual Hearing Exam 100% Hearing Aid 50% Hearing Aid Maintenance 100% Deductible Annual Hearing Exam $0 Hearing Aid $0 Hearing Aid Maintenance $0 Maximum (per benefit period) Annual Hearing Exam Up to $75 Hearing Aids (per ear) Year One Up to $200 Year Two Up to $600 Year Three Up to $800 Hearing Aid Maintenance Up to $40 Ameritas Rewards SM $100 Employee Participation Requirements All employees in the dental plan must participate if the hearing care plan is tied to dental. Page 26 3

6 Carter County Government Features/Benefits SoundCare SM Hearing Health Benefits Life's getting louder. SM Thanks to the cranked-up volume of modern life, hearing loss has become one of the most common chronic health problems in the U.S. It afflicts more than 30 million of us - about 10% of the population has a significant hearing loss - and the number is growing. Today's Baby Boomers have the most active and noisy lifestyle of any previous generation. And hearing loss is occurring at younger and younger ages, partly because of electronic devices that flood our society. In addition to the obvious culprits we're sticking in our ears - portable media players, cell phone earpieces, gaming headsets - here's a look at common noises that affect hearing, and the amount of time it can take for hearing loss to occur: stadium football game: two and a half hours tractor: 37 minutes hand drill: 23 minutes snowmobile: 15 minutes leaf blower, smoke alarm, chain saw, airplane cabin: a minute and a half rock concert, ambulance: 9 seconds An Important Addition To Your Benefits Package Employers of choice know the value of offering a competitive benefits package that demonstrates concern for the well-being of employees and their families. People usually mention sight and hearing as the two most important senses. Regular hearing screenings are a valuable but often overlooked habit for good health, because they alert people to hearing changes early and allow them to take protective measures before problems become serious. Treating hearing loss not only improves quality of life, it can improve employees' ability to communicate effectively on the job. Fortunately, most of the common forms of hearing loss including noise-induced hearing loss are treatable, primarily through the use of hearing aids. Sadly, less than 25% of people who can benefit are treated, often because of concerns about price. Hearing Plan Options Our SoundCare hearing health plans include three wellness benefit options to meet your needs and goals: hearing exams, hearing aids and hearing aid maintenance (complete plan) hearing aid and hearing aid maintenance hearing exam (available with our dental plan) Ameritas Rewards SM Ameritas Rewards is an enhanced product that offers an increased maximum for hearing, LASIK, orthodontia and vision as well as dental. It allows members to utilize unused dental maximum carryover amounts from previous years towards dental benefits or other lines of coverage included in a plan. Employees and their covered dependents may accumulate dental rewards with an unlimited maximum carryover amount. These rewards can be used to increase the maximum for the other lines of coverage which can then be used for certain covered services or materials subject to applicable deductible, coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. A member is eligible to earn rewards again the next year. Benefit Threshold $750 Dental benefits received for the year cannot exceed this amount Annual Carryover Amount $250 Ameritas Rewards amount is added to the following year's maximum Annual PPO Bonus $150 Additional bonus is earned if the member sees a PPO Provider Maximum Carryover Unlimited Maximum possible accumulation for Dental Rewards and PPO Bonus combined Ameritas Rewards SM Maximum Benefit Hearing Carryover Amount $100 Orthodontia Carryover Amount - Once per Lifetime $100 Page 27 4

7 Carter County Government Features/Benefits Rx Savings - Extra value for Ameritas plan members It's no secret that prescription medications can be one of the biggest - and most important - health care expenditures a person, family or organization faces. Not to mention, when a person requires long-term maintenance medications, it can become a serious budgeting issue. Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. If your organization offers its associates health care pharmacy benefits, this no-cost Rx discount could save significant dollars. Walmart's pharmacies will give Ameritas plan members their normal health care pharmacy benefit, or the Walmart Rx discount, whichever saves more. Members can get hundreds of generic drug prescriptions at the everyday low price of $4.00, in addition to saving approximately 40% off all other generics and 10-15% off most brand-name prescriptions. They can save even more with convenient home delivery mail-order service. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritasgroup.com and sign into (or create) a secure member account. That's where they can access and print an online-only Rx discount savings ID card. Also, when choosing eservices, your benefits administrator will have access to the online-only Rx discount savings ID card to assist members without Internet access. Eyewear Savings at Walmart Vision Centers Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritasgroup.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount. Also, when choosing eservices, your benefits administrator will have access to the Ameritas Eyewear Savings Card to assist members without Internet access. Page 28 5

8 Carter County Government Hearing Care Limitations/Exclusions Covered Expenses will not include and no benefits will be payable for expenses incurred for: examinations performed or supplies furnished before the member was covered under this section. subject to Extension of Benefits, any examination performed or supply furnished after the member's coverage under this section ceases. any hearing examination or supply required by an employer as a condition of employment, including but not limited to, any mandatory worksite programs designed to satisfy OSHA hearing conservation programs. replacement of hearing aids except once every 5 years from the date of placement of the hearing aid. This replacement interval is waived and 50% of the benefit that would be otherwise payable will be considered if all of the following conditions are met: the plan member is diagnosed with a significant deteriorations of hearing since placement of the previous hearing aid, and a statement from the provider is furnished indicating that the hearing aid being replaced cannot be modified to correct the loss, and at least 3 years has passed since placement of the previous hearing aid medical or surgical treatment of any part of the ear, including but not limited to, cochlear implants, or tubes in the ears. hearing care services or supplies in the first 12 months that a person is insured if the person is a late entrant, except hearing examinations. After this 12 month period, the maximum amount payable per plan member will begin at the 1st Benefit Period as shown in the Schedule of Benefits. which the plan member is entitled to benefits under any workers' compensation or similar law, or charges for services or supplies received as a result of any hearing loss caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit, including an occupational hearing loss. charges for which the plan member is not liable or which would not have been made had no insurance been in force. any procedure not shown in the Schedule of Hearing Care Services. any treatment which is for cosmetic purposes. assistive hearing devices not listed in the Schedule of Hearing Care Services, such as phone amplification, cellular phone amplifier, hearing aid dehumidifier, loop system, etc. charges for services not provided by a licensed provider, such as an audiologist, hearing aid specialist, otolaryngologist (ENT) or otologist (ear doctor), within the scope of that license. services or supplies which are not related to a conductive or sensorineural hearing loss, such as any nonorganic hearing loss or occupational hearing loss. charges for a hearing screening performed as a part of or in the course of any non-hearing routine examination. a hearing aid dispensed without the direction and supervision of a provider licensed to perform hearing aid examinations and/or hearing aid dispensing. because of war or any act of war, declared or not. removal of foreign bodies or ear wax from the ear or any part of the ear. Page 29 7