Dental Insurance: MetLife

Effective January 1, 2023 - December 31, 2024

MetLife Dental Insurance


IN THIS ARTICLE

MetLife Dental Details

Dental Coverage Details

Login to your Employee Portal

Find an In-Network Dentist

What to do BEFORE Getting Dental Services

Can I use my HRA card to pay for dental expenses?

Orthodontia Benefit Details

MetLife Dental Details

  • Provider: MetLife Dental
  • Website:  www.metlife.com/mybenefits               
  • App:  MetLife US                                                          
  • Plan Type:  PDP Plus
  • Network: Preferred Dentist Program - designed to provide the dental coverage you need with the features you want. Like the freedom to visit the dentist of your choice – in or out of the network. Find an In-Network Dentist. Click on Support, Find a Dentist. 
  • Group ID: 398356
  • Phone Number:  1-800-275-4638
  • Claim Address: 200 Park Ave., New York, NY 10166

Dental Coverage Details

What is covered by MetLife

  1.       "In-Network Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Network Benefits" refers to benefits provided under this plan for covered dental services that are not provided by a participating dentist. Utilizing an out-of-network dentist for care may cost you more than using an in-network dentist.
  2.       Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.
  3.       Applies to Type B and C services only.
  4.       Out-of-network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of:
    1.  the dentist’s actual charge (the 'Actual Charge'), 
    2.  the dentist’s usual charge for the same or similar services (the 'Usual Charge') or  
    3.  the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the 'Customary Charge').  For your plan, the Customary Charge is based on the 90th percentile.  Services must be necessary in terms of generally accepted dental standards.

What is not covered by MetLife:

  1. Orthodontic services must begin while this insurance is in force. If the insurance ends during the course of the treatment plan, the monthly benefits will end. Services are considered to have begun when the initial banding or appliance is inserted. For takeover groups with Orthodontic coverage under the prior carrier, we will pay for work in progress up to our lifetime maximum benefit considering any amounts already paid under the prior carrier. For takeover groups without Orthodontic coverage under the prior carrier, we will not pay for work in progress.
  2. Services must begin after the end of any applicable waiting period. Waiting periods for each category of service show on the schedule of benefits.
  3. When multiple dental services of similar types are provided, the frequency limit under the plan will combine all the similar types of services under the stated frequency limit in combination. Certain comprehensive dental services have multiple steps associated with them. These steps can be completed at one time or during multiple sessions. For benefit purposes under this plan, these separate steps of one service are considered to be part of the more comprehensive service. Even if the dentist submits separate bills, the total benefit payable for all related charges will be limited by the maximum benefit payable for the more comprehensive service. For example, root canal therapy includes x-rays, opening of the pulp chamber, additional x-rays, and filling of the chamber. Although these services may be performed in multiple sessions, they all constitute root canal therapy. Therefore, we will only pay benefits for the root canal therapy.

  4. Alternate Benefit: If We determine that a service, less costly than the Covered Service the Dentist performed, could have been performed to treat a dental condition, We will pay benefits based upon the less costly service if such service:

    would produce an equivalent therapeutic or diagnostic result as to the diagnosis or treatment of the individual's dental condition; and would qualify as a Covered Service. For example, if an amalgam filling and a composite filling are both professionally

    If We pay benefits based upon a less costly service in accordance with this subsection, the Dentist may charge for the difference between the service that was performed and the less costly service. This is the case even if the service is performed by an In- Network Dentist.

  5. acceptable methods for filling a molar, We may base our determination on the less costly amalgam filling.
  6.  Services which are not dentally necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature.
  7.   Services for which a covered person would not be required to pay in the absence of dental insurance.
  8.   Services or supplies received by a covered person before the insurance starts for that person.
  9.   Services which are neither performed nor prescribed by a dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for scaling or polishing of teeth or fluoride treatment.
  10.   Services which are primarily cosmetic unless required for the treatment or correction of a congenital defect of a newborn child.
  11.   Services or appliances which restore or alter occlusion or vertical dimension.
  12.   Restoration of tooth structure damaged by attrition, abrasion or erosion unless caused by disease.
  13.   Restorations or appliances used for the purpose of periodontal splinting.
  14.   Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.
  15.   Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.
  16.   Initial installation of a Denture to replace one or more teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.
  17.   Decoration or inscription of any tooth, device, appliance, crown or other dental work.
  18.   Missed appointments.
  19.   Services covered under any workers’ compensation or occupational disease law.
  20.   Services covered under any employer liability law.
  21.   Services for which the employer of the person receiving such services is not required to pay.
  22.   Services received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital.
  23.   Services covered under other coverage provided by the Policyholder.
  24.   Temporary or provisional restorations.
  25.   Temporary or provisional appliances.
  26.   Prescription drugs.
  27.   Services for which the submitted documentation indicates a poor prognosis.
  28.   Services, to the extent such services, or benefits for such services, are available under a government plan.  This exclusion will apply whether or not the person receiving the services is enrolled for the government plan.  We will not exclude payment of benefits for such services if the government plan requires that Dental Insurance under the group policy be paid first.
  29.   The following when charged by the dentist on a separate basis - Claim form completion; infection control such as gloves, masks, and sterilization of supplies; or local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.
  30.   Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing and biting of food.
  31.   Caries susceptibility tests.

Login to your Employee Portal

Access your dental information on the MetLife US Mobile App

Find an In-Network Dentist

  • Yes!  "In-Network" dentists will have the lowest costs! 

  • You can call your current dentist and ask if they are In-Network with MetLife (the PDP Plus Network).

  • You can click here to Find An In-Network Dentist. Click on Support, Find a Dentist 

  • Enter the plan type, PDP Plus and your zip code. There is also a box to search your current dentist to make sure they are in-network.  

  • You will see multiple dentists with a map. You can also filter your search. 

If you use an out of network dentist, the % of coverage (100%, 80%, or 50%) is the same, but MetLife will only pay that percentage up to the Maximum Allowable Amount.  

The Maximum Allowable Amount (MAC) is the maximum amount MetLife pays for a covred service from a provider, whether they’re in-network or out-of-network. What’s the difference, then? It comes down to your out-of-pocket cost. For instance, an in-network dentist may charge more for a procedure than your plan’s MAC fee. Because they’re in-network, though, they’ve agreed to accept the MAC fee. The difference between the provider’s charge and the MAC fee would be written off — you would not owe this difference. MetLife would then cover a percentage of the MAC fee, and you would owe any outstanding balance (coinsurance), assuming your deductible has been met. An out-of-network dentist, however, isn’t contractually obligated to accept the MAC fee. That means you’re responsible for coinsurance and any difference between the provider’s charge and the MAC fee.


What to do BEFORE a dental service - Can I get an estimate of what my out-of-pocket expenses will be before receiving a service?

  • Yes. Before you receive a dental treatment or service, you can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive a benefit estimate for most procedures while you are still in the office.
  • Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment. 

Can I use my HRA card to pay for my dental expenses?

  • Yes, but with limitations.  
    • If you have Single coverage, you can use up to $750 of your HRA dollars for dental expenses
    • If you have You + Spouse or You + Child coverage, you can use up to $1,125 of your HRA dollars for dental expenses.
    • I you have Family or You + Children coverage, you can use up to $1,500 of your HRA dollars for dental expenses.
  • Here's how the process usually works...
    • You go in for service.  Your dentist charges you what they think you owe based on their initial rates and an ESTIMATE of what your MetLife insurance will cover.  The dentist requires payment up front, so you pay - using your personal credit card.  (For an example, let’s say that for the two fillings, the initial rate was $500.  The dentist looks and sees that your insurance will cover 80% after a $50 deductible. So, they charge you $50 + (($500-$50)x.20) = $140.)
    • You get the fillings and your dentist files the claim with MetLife Insurance.  The dentist submits their initial rate to MetLife.
    • MetLife processes the claim and creates an EOB.  MetLife does not know what you may or may have not paid at the dentist office.  
    • On the EOB created by MetLife you see the initial rate (submitted rate) from the dentist and then you see the Allowed Amount.  The Allowed Amount is the actual amount that the dentist is allowed to charge for the service.  ALMOST EVERYTIME, the Allowed Amount is less than the initial (submitted) rate. (Using our example above, the initial rate was $500, but the EOB shows that the Allowed Rate is $400.  The actual amount you are responsible for paying the dentist is $50 + (($400-$50)x.20) = $120.  The EOB would show the Patient Responsibility to be $120.00 and that the dentist may bill you this amount.  BUT, at the time of service, you paid $140 to the dentist!  What does this mean?  It means that there should be a $20 credit on your account at the dentist office.)
    • Reconcile with your dentist.  Once MetLife processes the claim, the create and EOB that shows the ACTUAL amount you should have been charged for the services. If what you paid the dentist is MORE than what the EOB says your responsibility is, then you need to contact your dentist to get a refund.  If what you paid is LESS than what the EOB says is your responsibility, then your dentist may reach out to you to collect the difference.
    • Finally, you can submit that to EBC using their File A Claim process to be reimbursed the ACTUAL amount you should have been charged by the dentist.  Use the directions here on How to: File a Claim with EBC.  Make sure to only request reimbursement for the annual amount you are allowed (see above).

Wisdom Tooth Extraction Coverage

  • If you are going to have a tooth extracted (such as getting your wisdom teeth surgically removed), reach out to Denise to understand your full benefits for that surgery! There may be more coverage available to you!

Orthodontia Benefit Details

Our MetLife Dental Insurance policy pays 50% of orthodontia treatment up to a $1,000 lifetime payout maximum, per child up to 26 years of age. In order to be good stewards of the church's finances and the insurance policies that we invest in, it is important to first utilize the coverage already provided by our MetLife Dental Insurance. To maximize this benefit and keep costs low, it is important to receive treatment from an in-network orthodontist.

For qualified full-time employees, TASCC will reimburse additional expenses paid toward your child’s orthodontics (braces, Invisalign, spacers, etc.). Each full-time staff member is eligible to reimburse a lifetime max of $3,000 per child up to age 18. This is a taxable reimbursement benefit.

To receive reimbursement, you must submit the orthodontia payment receipt and treatment plan to payroll@austinstone.org in order to receive the taxable reimbursement on your paycheck. Only treatment received while the employee is active and full time is eligible for reimbursement.

Full-time staff members who's child already began orthodontia treatment on the Austin Stone's dental plan prior to January 2017, are eligible to reimburse a lifetime max of $4,000 toward that child's orthodontia treatment (in order to avoid changing treatment to an in-network provider).

Participation in this benefit ends as of an employee's last day of employment.