dental & vision enrollment

Transcription

1 North Carolina Retired Governmental Employees Association 2016 dental & vision enrollment Enroll Now thru Oct. 31, 2015 Optional Dental and Vision Plans Offered through your membership with the NCRGEA

2 Dear NCRGEA Member, We are pleased to again o er you an opportunity to enroll in our optional dental and vision care insurance plans. The group dental plan is o ered by MetLife, our partner for the past fourteen years in the provision of quality dental insurance coverage for our members. Superior Vision provides our group vision insurance plan and has been our provider for the past six years. The enclosed brochure provides information on these two insurance programs, including bene t summaries, descriptions of coverage types, and monthly premiums. The brochure includes tear-out enrollment forms for both the dental and vision insurance programs. The insurance premiums and membership dues are deducted from your monthly pension bene t. Although, premium and dues deductions are not available to Associate members or to members receiving checks through the State Disability Income Plan or alternative retirement plans, such as TIAA-CREF, other options are available just contact NCRGEA for details. If you decide to enroll in either or both of these optional insurance plans, please complete the appropriate enrollment form(s) and return to NCRGEA in the enclosed preaddressed envelope no later than October 31, Once you are enrolled, the rst monthly premium will be deducted from your December retirement bene t on December 18, 2015 and your insurance coverage will begin on January 1, Your coverage will apply to services incurred on and after January 1, You already may be enrolled in other dental and vision insurance coverage. Enrollment in our MetLife Dental or Superior Vision insurance plans will not cancel your other coverage. It is your responsibility to contact the provider to cancel your current coverage. Please contact us at the following numbers if you need more details or if you have any questions: Toll free , or info@ncrgea.com. Sincerely, Richard E. Rogers, Jr., Executive Director

3 in the state legislature, membership in the Association also provides you with the opportunity to take advantage of our optional MetLife Dental and Superior Vision insurance plans. From now until October 31, 2015, we invite you to enroll yourself and your dependents! MetLife Dental Plan -page 4- Superior Vision Plan -page 8- $2,000 Available Day 1 - No Annual Deductible Substantial Savings for using In-Network Dentists - Enroll on page 11 - Coverage for eye exams and materials Large providerr network across NC Lots of discounts available! - Enroll on page 13 - Cost Savings Available through the NCRGEA Dental With a MetLife Dental PPO plan, you can visit any licensed dent When you choose a participating dentist you could save even more since dentists in network accept negotiated fees that are typically 15-45% less than the average charges in the same geographical area. 1 And you know you are always in good hands because providers are selected based upon strict credentialing criteria. 2 This program ting dentist go to and enter a dentist near you. It s just that simple. Also, if you are out of the country and need emergency care we have an international travel assistance 3 servi ces program. You never have to worry. Plus, your coverage will be considered under your out-of-networ dental services. Apart from a large national network, you also get 100% coverage for preventive care, which includes When you choose a participating dentist you have lower out-of-pocket costs. Below is an example of the cost difference for a porcelain crown across North Carolina when visiting a participating dentist. Labeled by the First Three Digits of the Zip Code 3 Enroll Now thru Oct. 31, 2015

4 Dental Program Bene t Summary Prepared for NCRGEA Annual Deductible $0 per Individual Total Annual Maximum $2,000 per Individual Category Preventive - Procedures covered at 100%** Oral Exams Cleanings Topical Fluoride Application Bitewing X-rays Full Mouth X-rays Palliative (Emergency) Treatment Space Maintainers Sealants Oral Cancer Screening Minor Restorative - Procedures covered at 60%** Amalgam Restorations (Fillings) Resin Restorations (Fillings) Crown and Bridge Repairs Periodontal Scaling/Root Planing Periodontal Maintenance Therapy Periodontal Surgery Simple and Surgical Extractions Oral Surgery Endodontics/Root Canals General Anesthesia Consultations Major Restorative/Dentures - Procedures covered at 50%** Bridges Dentures*** Denture Repairs Adjustments to Dentures*** Denture Relining and Rebasing*** Tissue Conditioning Crowns Implants Frequency Limitations 2 per calendar year 2 per calendar year 1 per calendar year (Child & Adult) 1 set per calendar year 1 per 60 months Once per lifetime per area up to age 19 Once per 60 months up to age 19 1 per 24 months per quadrant 4 per calendar year, including 1110 Once per quadrant every 36 months Some limits apply (see Certi cate) Once per tooth per 24 months When dentally necessary or in connection with complex surgery, max up to 2 hours 1 per 12 months Replace once every 5 years Replace once every 5 years 1 per tooth every 5 years Once every 5 years per tooth The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document presents the majority of services and limitations within each category, but is not a complete description of the Plan. A Certificate will be made available following your plan s effective date, and will govern if any discrepancies exist between this overview and the actual Certificate. **Percentages of Usual & Customary Fees ***Relining or Rebasing of existing Removable Dentures will be a Covered Dental Expense not more frequently than once every 36 months (covered only after a minimum of six months after the initial installation of the device.) 4

5 Monthly Rates Member Only $46.24 Member + Child(ren) $72.00 Member + Spouse $ Member + Family $ Exclusions: Services Not Covered Under Your Dental Plan 1. Missing tooth exclusion 2. Services or supplies received by a covered person before the dental expense bene ts start for that person 3. Services not performed by a dentist except for those services of a licensed dental hygienist, that are supervised and billed for by a dentist and which are for cleanings and scaling of teeth or uoride treatments 4. Services or supplies that are covered by any Workers Compensation law or any Occupational Disease law 5. Services or supplies that are covered by any Employer s Liability law 6. Services or supplies that any plan sponsor is required by law to furnish, in whole or in part 7. Services or supplies received through a medical department or similar facility that is maintained by any covered person s plan sponsor 8. Services or supplies received by a covered person for which no charge would have been made in the absence of dental expense bene ts for that covered person 9. Services or supplies for which a covered person is not required to pay 10. Services or supplies that are deemed experimental in terms of generally accepted dental standards 11. 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, that occurs while the dental expense bene ts for the covered person are in effect 12. Adjustment of a denture that is made within six months after installation by the same dentist who installed it 13. Use of materials to prevent decay other than uorides (for dependent children and adults) and sealant materials (for one treatment of a molar tooth for a dependent child under age 19) 14. Instruction for oral care such as hygiene or diet 15. Services or supplies to the extent that bene ts are otherwise provided under this plan or under any other plan that the plan sponsor or employer contributes to or sponsors 16. Periodontal splinting 17. Any duplicate appliance or prosthetic device 18. Replacement of a lost, missing or stolen crown, bridge or denture 19. Myofunctional therapy or correction of harmful habits 20. Charges for missed appointments 21. Charges by the dentist for completing claim forms 22. Sterilization services 23. Services or supplies furnished by a family member 24. Consultations or exams, other than routine exams, when performed in conjunction with related treatments 25. Orthodontia 26. Treatment of Temporomandibular Joint Disorders (TMJ) 27. Cosmetic surgery, treatments or supplies unless required for the treatment or correction of a congenital defect of a newborn dependent child 5 Enroll Now thru Oct. 31, 2015

6 Important MetLife Dental Enrollment Information Initial Enrollment for Active Members Two-year lock in. You may enroll only during NCRGEA s open enrollment period for dental coverage. Once you have enrolled, you must stay enrolled for the duration of the plan, which is offered on an every other year basis. If you choose to discontinue coverage at any point in time, you will not have the opportunity to re-enroll, unless you have a qualifying change in family status. Qualifying events include marriage, divorce, birth or adoption of a child, death of a dependent, and the end of existing COBRA coverage. There are two allowable exceptions to enroll in the plan. First, if you choose to elect COBRA at retirement you have the option to join the plan after your COBRA expires. Secondly, if you choose not to enroll in the plan because you are covered by your spouse s plan and your spouse retires, you are able to choose to enroll either at your spouse s retirement or when your spouse s COBRA coverage expires. Coverage is only available through pension deduction. New Members When you become a new member of NCRGEA, you have a 60-day eligibility period in which to enroll. If you elect not to enroll, you will not have the opportunity to enroll at a later date. All other enrollment rules as described for Active Members above would subsequently apply to New Members. Ongoing Enrollments Eligibility for re-enrollment occurs on a two-year cycle from the effective date. Those who are currently in the plan may either elect to remain in the plan or disenroll at this time. If the member remains, he/she participates for another two-year plan duration. Written intent to disenroll should be received by the NCRGEA 45 days prior to the end of the two-year cycle. 30-day post enrollment window You can change your enrollment option for coverage within 30 days if no claims have been submitted/paid. Any claim submitted (subsequent to or before disenrollment) by a participant who disenrolls will be denied. After the initial 30-day post enrollment window, you will be locked in for the duration of the current two-year plan. Frequently Asked Questions How does the plan work? You and your dependents have complete freedom of choice to visit any dentist you wish. Reimbursement percentages are based on the nature of work you receive. The Program Summary on page three shows the speci c services covered. Please take this overview to your dentist for discussion and clari cation. Can I use this plan outside of North Carolina? Yes. The MetLife plan provides you with access to a nationwide network of dental care providers. You may call to request a directory of network providers for a particular area or visit 6

7 What if my dentist isn t a MetLife participating dentist? You can visit any dentist and still receive bene ts under your plan. However, we encourage you to consider using a participating dentist to maximize the value of your plan. If your current dentist does not participate in the MetLife plan and you d like to encourage him or her to apply for membership, tell your dentist to visit or call MET-DDS9. Note that this website and phone number are speci cally for dentists and not accessible to members. How do I le a claim? Your dentist will usually le your claims for you. If you need a claim form, they are available by either calling MetLife s Dental Customer Service Department s toll-free number at or they can be downloaded and printed from MetLife s dental web site at Remember to bring a claim form with you to your dental appointment. Complete the retiree portion, and your dentist will assist you with the rest. After each claim submission, unless charges are covered in full, you will receive a concise explanation of bene ts (EOB) statement. Can I nd out how much services will cost and obtain an estimate of what the plan will cover prior to treatment? Yes. MetLife strongly recommends that you have your dentist submit a pretreatment estimate to MetLife if the cost is expected to exceed $300. When your dentist suggests treatment, have him or her send a claim form, along with the proposed treatment plans and supporting documentation, to MetLife. An explanation of bene ts (EOB) will be sent to you and the dentist detailing an estimate of what services MetLife will cover and at what payment level. Is it necessary to have my premiums and NCRGEA dues deducted from my retirement check? Yes, premiums and NCRGEA dues must be deducted from your retirement check. Whom do I call with questions? For questions regarding NCRGEA membership dues deductions or MetLife dental plan premium deductions, call NCRGEA at NCRGEA s normal hours are Monday through Friday from 8:00 a.m. until 5:00 p.m. Eastern time. Please note that if your dues have been paid for the current year, no deduction will be made for dues until the month prior to your renewal date. For questions regarding the dental plan, please call MetLife s Dental Customer Service Department s toll-free number at You can call Monday through Friday from 8:00 a.m. until 11:00 p.m. Eastern time. When will I have access to MetLife s mybene ts website? You now have access to the MetLife s mybene ts website by going to ts and entering NCRGEA s name. By having access, you can search our Find a Participating Dentist online directory and download a claim form. Why wait for your claims to arrive in the mail when you can receive immediate noti cation that your claim has been processed and more! This information provides plan highlights only. Upon enrollment, you will receive further communication materials detailing plan provisions. Like most group health insurance policies, MetLife group policies contain certain exclusions, limitations, waiting periods and terms for keeping them in force. Metropolitan Life Insurance Company, New York, NY L [exp0914][All States] Enroll Now thru Oct. 31,

8 Monthly Premiums Retiree Only $7.32 Retiree and Family $16.74 Co-pays Exam $20 Materials (not applicable to contact lenses) $15 Contact Lens Fittings $20 Co-pays apply to in-network benefits, co-pays for out-of-network visits are deducted from reimbursements. Services/Frequency Exam 12 Months Frames 24 Months Contact Lens Fitting 12 Months Lenses 12 Months Contact Lenses 12 Months North Carolina Retired Governmental Employees Association 3 ways to get eye and vision health information, eye care tips, fun facts and more! Visit the Vision Care Learning Center at: Superiorvision.com Frequency is based of date of service Benefits Exam (Ophthalmologist) Exam (Optometrist) Frames Contact Lens Fitting (Standard 1 ) Contact Lens Fitting (Specialty 1 ) Lenses (Standard) per Pair: Single Vision Bifocal Trifocal Progressive lens upgrade Contact Lenses 3 Medically Necessary Contact Lenses In-Network Covered-in-full after $20 co-pay Covered-in-full after $20 co-pay $130 retail allowance after $15 co-pay Covered-in-full after $20 co-pay $50 retail allowance after $20 co-pay Covered-in-full after $15 co-pay Covered-in-full after $15 co-pay Covered-in-full after $15 co-pay See Description 2 $120 retail allowance Covered-in-full Up to $44 retail Up to $39 retail Up to $63 retail Not Covered Not Covered Up to $34 retail Up to $48 retail Up to $64 retail Up to $64 retail Up to $100 retail Up to $210 retail All allowances are at a retail value; member is responsible for any amount over the allowance, minus available discounts. 1 Standard contact lens fitting applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses only. The specialty contact lens fitting applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. For the specialty fitting, the member is responsible for any charges over $50. 2 Covered to the provider s in-office retail price for standard lined trifocal; member pays difference between the progressive and the trifocal, minus a 20% discount on the overage. Applicable co-pay applies. 3 Contact lenses are in lieu of eyeglass lenses and frames benefit. 8

9 How to Use the Plan Welcome to the Superior Vision Plan. Superior Vision provides primary vision care bene ts including eye examinations, prescription eyewear, and contact lenses through a broad-based provider network of both ophthalmologists and optometrists. The plan also contracts with a large number of national and regional optometric chain locations. Your rst step should be to choose an eye care provider, or ensure that your current provider is part of the Superior Vision network. Go to SuperiorVision.com and click on Locate a Provider for an updated list. You may also call Customer Service for this information at You will learn about in-network and out-of-network providers it is an important distinction when receiving your bene ts. You will also learn more about how to use your bene ts, as well as the discounts that are available to you. Superior Vision eye care providers will be looking for signs that may indicate other health issues - not just vision problems. Take the time to get to know your vision plan, and start experiencing healthy eyes and healthy living. Remember that a routine eye exam is important not only for correcting vision problems, but for maintaining healthy eyes and overall wellness. Discount Features Discounts vary by provider but are the best possible discounts available to our members. Visit our website or call Customer Service to get provider speci cs. Discounts on Covered Materials Frames: 20% discount off the difference between your chosen retail frame and the retail frame allowance. Lens Options & Upgrades: 20% discount off retail rate. Some options on certain lenses are discounted to a speci c amount; this list does NOT include high-end, name brand, or nonstandard options. Fixed price standard options on standard lens types include Factory Scratch coat ($13), UV coat ($15), Anti-Re ective ($50), glass coloring ($35), and solid and gradient tints ($25). On standard single vision lenses, xed price standard options include High Index 1.6 ($55), Polycarbonate ($40), and Photochromic ($80). Materials Discounts on Additional Purchases (off retail prices) Prescription eyeglass lenses 30% Eyeglass frames 30% Lens options & upgrades 20% Contact lenses (hard or soft) 20% Disposable contacts 10% Discounts are subject to change without notice. Discounts do not apply when prohibited by the manufacturer. Monthly Rates Retiree Only $7.32 Retiree and Family $16.74 Enroll Now thru Oct. 31,

10 Items or Services Not Covered While Superior Vision offers a variety of vision bene ts, there are a few materials, services, and treatments that are generally not covered, or have limitations to their coverage. We do offer discounts on many of these items, as outlined in our discount description. Items or Services Not Covered or Limited Coverage* Non-prescription (plano) lenses of any kind, sunglasses, or contact lenses Any coating applied to lenses such as anti-re ective, scratch, UV, lamination, tints (except pink tint #1 and #2), and sunglass coloring Any lens materials other than standard plastic or glass such as polycarbonate, hi-index, polaroid, and photochromic Any special lens feature or treatment such as prisms, slab off, faceted, oversize lens greater than 61mm, polished bevel, groove, drill mount, notch, roll and polish, and blended bifocal Progressive lenses (the provider will apply the retail charge for standard trifocal lenses against the retail charge for the progressive lenses you selected.) Replacement of broken, lost, or damaged frames and/or lenses Orthoptics, vision training, and developmental vision procedures Experimental or non-conventional treatment or device Medical or surgical treatment of the eyes Post-cataract lenses (intra-ocular) subnormal or low vision aids Safety eyewear Eye examination or corrective eyewear required by an employer as a condition of employment Services or materials when covered under workers compensation or similar third party coverage Services or materials rendered by a provider other than an ophthalmologist, optometrist, or optician acting within the scope of his or her license Any additional services or procedures outside of a routine eye exam and contact lens tting Services or materials rendered after the date a member ceases to be covered by the bene ts plan except when vision materials ordered before coverage ended are delivered AND the corresponding services are provided to the member within 31 days of the initial order Regardless of optical necessity, bene ts are not available more frequently than that which is speci ed in the Outline of Bene ts. * Plans vary, please refer to your own speci c coverage. Disclaimer: All nal determinations of bene ts, administrative duties, and de nitions are governed by the Certi cate of Insurance Coverage for your vision plan 10 How to Reach Superior Vision Customer Service TDD (Hearing Impaired) fax Authorization numbers (out-of-network) Explanation of bene ts Provider locator; provider nomination Claims inquiry Grievance issues Claims Administration PO Box 967 Rancho Cordova, CA Corporate/Customer Service White Rock Rd. Rancho Cordova, CA contactus@superiorvision.com Administered by: Superior Vision Services, Inc White Rock Road, Rancho Cordova, CA Underwritten by: National Guardian Life Insurance Company National Guardian Life Insurance Company is not af liated with The Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life. Enroll Now thru Oct. 31, 2015

11 ENROLLMENT FORM FOR NCRGEA - METLIFE GROUP DENTA L COVERAGE Group Name: North Carolina Retired Governmental Employees Association Group Number: TO BE COMPLETED BY NCRGE A MEMBER - PLEASE PRINT LEGIBLY - Directions: 1. Complete all responses. Incomplete forms cannot be processed. 2. This form must be signed to be processed. Name: Last First MI Address:. DO NOT WRITE IN THIS AREA FOR OFFICE USE ONLY TO BE COMPLETED BY NCRGEA Based on the coverage chosen, the dental premium deduction will be $ PER MONTH Tear Along Dotted Line City: State: ZIP Code: Social Security Number: Date of Birth (Mo/Day/Yr): Home Telephone Number (Include Alternate Telephone Number (Cell or Address: Area Code): Work): PLEASE MARK ONE BOX BELOW TO SELECT THE DENTA L PLAN DESIRED: Member Only Coverage Member and Dependent* Member and Spouse** Member and Spouse and Dependent* *Dependent Children may be covered until their 26th birthday. **If Spouse and/or Dependent coverage is selected, please complete table below. made on 25, 201. If the dues are not currently being will be made on 25, 201. for a dues renewal date of, 201. Based on the yearly dues of $, the dues deduction will be $ PER MONTH. Name (Last, First MI) Relationship Date of Birth PA YROLL DEDUCTION AUTHORIZATION: A SPOUSE / / CHILD / / CHILD / / CHILD / / I received and read a copy of NCRGEA s current description of the group dental plan insured and administered by Metropolitan Life Insurance Company. If I qualify for payroll deduction, I agree to remain in the NCRGEA Dental Plan until December 31, By signing below, I declare that all the information given in this enrollment form is true and complete to the best of my knowledge and belief. I hereby authorize the North Carolina Retirement System to deduct from my retirement account both my membership dues and/or my monthly dental plan premium as I ve indicated above. If your NCRGEA membership dues have been paid for the current year, we will begin your dues deduction the month prior to your next scheduled renewal date. This authorization applies to such coverage until I rescind it in writing. Member s Signature Date (Mo/Day/Yr) If you have questions about this plan and/or the plan s coverage, please call toll free at Mail the completed enrollment form to: NCRGEA, PO Box 10561, Raleigh, NC

12 Page Intentionally Left Blank 12

13 Vision Coverage North Carolina Retired Governmental Employees Association Enrollment Form Retiree instructions for completing the Vision Plan enrollment form: 1. Please type or print all information when completing this form. 2. Please complete all the information under the Retiree Information, Type of Coverage and Dependent Information headings. 3. Please review the enrollment form to ensure all information is accurate and readable. Sign and date form. 4. Upon completion of this form, return it in the enclosed reply envelope provided. 5. Questions regarding the insurance plan? Call Questions regarding NCRGEA membership dues? Call or Tear Along Dotted Line Retiree Information - to be completed by retiree Social Security # / / Date of Birth / / Home Phone ( ) Last Name First Name MI Street Address City State Zip Code Sex M F Type of Coverage - to be completed by retiree Retiree only $7.32 / Month Retiree and Family $16.74 / Month DO NOT WRITE IN THIS AREA FOR OFFICE USE ONLY (TO BE COMPLETED BY NCRGEA) Based on the coverage chosen, your vision premium deduction will be $ PER MONTH Your first premium deduction will be made on 25, 20 If your dues are not currently being deducted, the first dues deduction will be made on 25, 20 Based on your yearly dues of $, your dues deduction will be $ PER MONTH Dependent Information - to be completed by retiree Last Name First Name MI Sex Date of Birth Relationship M F / / M F / / M F / / M F / / M F / / Retirement Payroll Deduction Authorization (this section must be signed to receive benefits) I hereby authorize the North Carolina Retirement System to deduct from my retirement account, both my NCRGEA membership dues and my vision plan premiums. This authorization applies to such coverage until I rescind it in writing. Signature Date / / Mail Application in enclosed self-addressed envelope to: NCRGEA, PO Box Raleigh, NC 27605

14 Page Intentionally Left Blank 14

15 Frequently Asked Questions I have additional questions about the dental and/or vision plan - who should I call? You may contact the NCRGEA at or the Association at info@ncrgea.com. How do I enroll? Enrollment is easy! Simply ll out the appropriate form and mail it back in the enclosed pre-addressed envelope to the NCRGEA at PO Box 10561, Raleigh, NC Who is eligible to enroll? All active members of the NCRGEA are eligible to enroll. Also eligible to be covered are enrollees legal spouses and dependent children under the age of 26. What do I need to do if my dependent is no longer eligible? Upon the date of ineligibility (death of dependent, divorce of spouse, or dependent s 26 th birthday, etc.), please contact the NCRGEA to have your dependent removed from the plan. Will I receive an ID card? Yes. When you enroll, you will receive an ID card in the mail from MetLife Dental and/or Superior Vision prior to January 1st. How do I nd a dental or vision provider? To locate a dental provider, visit or call To locate a vision provider, visit or call How do I pay my monthly premiums? Your monthly premiums will be conveniently deducted from your state or local government retirement check. Contacts and Resources Customer Service Website North Carolina Retired Governmental Employees Association Customer Service Website Customer Service Website Enroll Now thru Oct. 31,