NEW YORK HEALTH BENEFITS (EHB) PLAN

Transcription

1 SCHEDULE OF BENEFITS NEW YORK HEALTH BENEFITS (EHB) PLAN SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Participating Provider Member Responsibility for Non-Participating Provider Member Responsibility for Deductible One (1) Member under Age 19 Two (2) or More Members under Age 19 $100 $100 Subject to one combined deductible for both innetwork and out-ofnetwork Out-of-Pocket Limit One (1) Member under Age 19 $350 Two or More Members under Age 19 $700 Annual Maximum $0 $400 See the Cost- Sharing Expenses and Allowed Amount section of this Certificate for a description of how We calculate the Allowed Amount. Any charges of a Non- Participating Provider that are in excess of the Allowed Amount do not apply towards the Deductible or Out-of- Pocket Limit. You must pay the amount of the Non- Participating Provider s charge that exceeds Our Allowed Amount. NY 1

2 PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Pediatric Dental Care Preventive Dental Care Routine Dental Care Participating Provider Member Responsibility for Non-Participating Provider Member Responsibility for Limits 10% Coinsurance 10% Coinsurance One Dental Exam & Cleaning Per 6 Month Period 10% Coinsurance 10% Coinsurance Full mouth X-rays or panoramic X-rays per 36 month period and bitewing X-rays per 6 period Endodontics 50% Coinsurance 50% Coinsurance Periodontics 50% Coinsurance 50% Coinsurance Prosthodontics 50% Coinsurance 50% Coinsurance Orthodontics 50% Coinsurance Non-Participating Provider Services Are Not Covered and You Pay the Full Cost Oral Examinations 10% Coinsurance 10% Coinsurance Once every 6 Limited oral evaluation problem focused 10% Coinsurance 10% Coinsurance Once every 6 combined with Oral Examinations limitation Periapical X-Rays 10% Coinsurance 10% Coinsurance Bitewing X-Rays 10% Coinsurance 10% Coinsurance 1 set in 6 Full-mouth X-Rays 10% Coinsurance 10% Coinsurance 1 set every 36 Other X-Rays 10% Coinsurance 10% Coinsurance Prophylaxis Cleanings 10% Coinsurance 10% Coinsurance 1 time per 6 including full mouth debridement Fluoride 10% Coinsurance 10% Coinsurance 1 time in 6 Sealants 10% Coinsurance 10% Coinsurance One per tooth per 36 (per permanent 1 st and 2 nd non-restored molar) NY 2

3 Preventive resin restoration in a moderate to high caries risk patient permanent tooth Palliative (Emergency) Treatment of dental pain minor procedure 10% Coinsurance 10% Coinsurance One per tooth per 36 (per permanent 1st and 2nd non-restored molar) 10% Coinsurance 10% Coinsurance Space Maintainers 10% Coinsurance 10% Coinsurance Once per lifetime per area Periodontics Non-Surgical 50% Coinsurance 50% Coinsurance Periodontal Maintenance 50% Coinsurance 50% Coinsurance Periodontal Scaling and Root Planing 50% Coinsurance 50% Coinsurance 4 times in any Plan Year less the number of teeth cleanings received during such Plan Year. Periodontal maintenance is a Covered Service only where periodontal treatment (including scaling, root planning and periodontal surgery such as gingivectomy, gingivoplasty and osseous surgery) has been performed. 1 quadrant, or area, in any per 24 Recementations 50% Coinsurance 50% Coinsurance 1 per 12 consecutive Pulpotomy 50% Coinsurance 50% Coinsurance Pulp Capping 50% Coinsurance 50% Coinsurance Pulp Therapy 50% Coinsurance 50% Coinsurance Prefabricated Crowns 50% Coinsurance 50% Coinsurance 1 replacement per 84 consecutive NY 3

4 Sedative Fillings 50% Coinsurance 50% Coinsurance Amalgam Fillings 50% Coinsurance 50% Coinsurance 1 per tooth surface per 24 Resin Composite Fillings 50% Coinsurance 50% Coinsurance 1 per tooth surface per 24 Simple Repairs of Cast Restorations 50% Coinsurance 50% Coinsurance 1 per 12 consecutive Apexification & Recalcification 50% Coinsurance 50% Coinsurance Denture Adjustments 50% Coinsurance 50% Coinsurance 1 per 12 consecutive, if at least 6 have passed since installation Dentures Rebases/Relines 50% Coinsurance 50% Coinsurance Office or laboratory relines or rebases are limited to one per arch in any 36 consecutive, if at least 6 have passed since installation Fixed Partial Dentures 50% Coinsurance 50% Coinsurance 1 per 84. Fixed partial Dentures are only available if Medically Necessary and will be used only when a partial cannot satisfactorily restore the case. If fixed partial Dentures are used when a partial could satisfactorily restore the case, the benefit determination will be based upon the partial which is the less costly service. NY 4

5 Repair of Dentures 50% Coinsurance 50% Coinsurance 1 per 12 consecutive Debridement 50% Coinsurance 50% Coinsurance Once per lifetime in combination with prophylaxis General Anesthesia- Intravenous Sedation and Inoffice conscious sedation 50% Coinsurance 50% Coinsurance General anesthesia or intravenous sedation or In-office conscious sedation in connection with oral surgery, extractions or other Covered Services, is only a Covered Service when such anesthesia is determined to be Medically Necessary. Periodontal Surgery 50% Coinsurance 50% Coinsurance 1 quadrant, or area, in any 36 month period. Periodontal surgery includes gingivectomy, gingivoplasty and osseous surgery. Periodontal Surgery - Soft and Connective Tissue Grafts Oral Surgery Simple Extractions 50% Coinsurance 50% Coinsurance 1 per unique site per 36 50% Coinsurance 50% Coinsurance Oral Surgery Surgical 50% Coinsurance 50% Coinsurance Extractions Consultations 50% Coinsurance 50% Coinsurance 2 per 12 consecutive NY 5

6 Dentures Complete/Partial 50% Coinsurance 50% Coinsurance 1 replacement per 84 consecutive. Dentures, full maxillary, full mandibular, partial upper, partial lower, teeth, and clasps and are only available if Medically Necessary. Adding teeth to Dentures 50% Coinsurance 50% Coinsurance Tissue Conditioning 50% Coinsurance 50% Coinsurance 1 per 36 consecutive Orthodontics 50% Coinsurance not subject to Deductible Non-Participating Provider Services Are Not Covered and You Pay the Full Cost Orthodontia services are limited to a Child under age 19. Orthodontia services must be Medically Necessary. Orthodontia treatment must begin while this insurance is in force. If the insurance ends during the course of the treatment, the monthly payments will end. Orthodontic services are covered under the plan if they are Medically Necessary to treat a handicapping malocclusion, as determined by MetLife. Dental procedures performed in connection with Orthodontia treatment are considered under the orthodontia benefit and are Covered Services only if Medically Necessary. Orthodontic treatment generally consists of initial placement of an appliance and periodic follow-up visits. The benefit payable for the initial placement will not exceed 20% of the amount charged by the Provider. The balance of the treatment fee will be paid proportionately during the remaining course of treatment. NY 6

7 DENTAL INSURANCE: EXCLUSIONS No coverage is available under this Certificate for the following: A. Cosmetic Services. We do not Cover cosmetic services or surgery unless otherwise specified, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Child which has resulted in a functional defect. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeals sections of this Certificate unless medical information is submitted. B. Coverage Outside of the United States, Canada or Mexico. We do not Cover care or treatment provided outside of the United States, its possessions, Canada or Mexico except for Emergency Dental Care as described in the Pediatric Dental Care section of this Certificate. C. Experimental or Investigational Treatment. We do not Cover any health care service, procedure, treatment, or device that is experimental or investigational. However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials, We will not Cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under the Certificate for non-investigational treatments. See the Utilization Review and External Appeal sections of this Certificate for a further explanation of Your Appeal rights. D. Medically Necessary. In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Certificate. E. Medicare or Other Governmental Program. We do not Cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid). F. Military Service. We do not Cover an illness, treatment or medical condition due to service in the armed forces or auxiliary units. G. No-Fault Automobile Insurance. We do not Cover any benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. This exclusion applies even if You do not make a proper or timely claim for the benefits available to You under a mandatory no-fault policy. H. Services not Listed. We do not Cover services that are not listed in this Certificate as being Covered. DENTAL INSURANCE: EXCLUSIONS (Continued) I. Services with No Charge. We do not Cover services for which no charge is normally made. J. Workers Compensation. We do not Cover services if benefits for such services are provided under any state or federal Workers Compensation, employers liability or occupational disease law. Metropolitan Life Insurance Company, New York, NY L [exp1215][NY] NY 7