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h`06NH+500 0000378718 00000 n 0000001651 00000 n There are thousands of PDP Plus Network general dentists and specialists to choose from nationwide so you are sure to find one who meets your needs. Please refer to your Evidence of Coverage or call Customer Service at the number on the back of your Humana ID card to confirm that the service will be covered by your plan. ic+C@nN`RYva@\}KRr>Wq8=Rw+{a .n!LF40d=DdcB42r7hRXyMQ"wDYfuwO se)D+jd7bLB,2}a'_UOaB:.bwRIQGp)` aHeO\@qPtn#u,{n{@|=V<^N}Ap2,+H>0$_ -C 0000007939 00000 n All rights reserved. If it contains a form, you can print it and fill it out. Please Note: Additional information about this benefit change will be posted as it becomes available and before the July 1, 2023 effective date. These rules determine the order in which the plans will pay benefits. search a list of these participating dentists online, https://www.metlife.com/support-and-manage/forms-library/, One fluoride treatment per 12-month period for dependent children up to their 14th birthday, Total number of periodontal maintenance treatments and prophylaxis cannot exceed two treatments in a calendar year, For dependent children up to 14th birthday, once per lifetime per tooth area, One application of sealant material every 60 months for each non-restored, non-decayed 1st and 2nd molar of a dependent child up to their 16th birthday, Crown, Denture, and Bridge Repair / Recementations, Initial placement to replace one or more natural teeth, which are lost while covered by the plan, Root canal treatment limited to once per tooth per lifetime, When dentally necessary in connection with oral surgery, extractions or other covered dental services, Except as mentioned elsewhere in certificate, Periodontal scaling and root planning once per quadrant, every 24 months, Your Children, up to age 19, are covered while Dental Insurance is in effect. Pre-authorization will still need to be submitted by your provider to SurgeryPlus before the surgery is scheduled. To connect with SurgeryPlus today, call 833-709-2445. References to UnitedHealthcare pertain to each individual company or other UnitedHealthcare affiliated companies. The time a mother and baby spend in the hospital after delivery is a medical decision. Some types of surgery also change the connection between your stomach and intestines. If you need a claim form, visit https://www.metlife.com/support-and-manage/forms-library/ or request one by calling 1-800-942-0854. Home health services, Medicare.gov, last accessed June 10, 2022. 0000379543 00000 n <>/Filter/FlateDecode/ID[<4A8EC73074B5B2110A00B0B8D090FC7F>]/Index[988 109]/Info 987 0 R/Length 162/Prev 206109/Root 989 0 R/Size 1097/Type/XRef/W[1 3 1]>>stream Visit ESPN for the game videos of the Brooklyn Nets vs. Boston Celtics NBA basketball game on March 3, 2023 He or she hasnt agreed to accept negotiated fees. A prime example is breast implants done during or after breast cancer surgery. Mastectomy surgery is a significant life event for many people. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. 125 0 obj <>stream Click Register Now to create your profile and start exploring this free service. However, this depends on the specific type of surgery you need, your dental plan, and your level of coverage. Negotiated fees are subject to change. Delaware Courts If the MetLife dental benefit plan is secondary, most coordination of benefits provisions require MetLife to determine benefits after benefits have been determined under the primary plan. These partners are required to comply with all laws protecting privacy. %PDF-1.6 % SurgeryPlus is a voluntary benefit that provides pre-planned, non-emergency surgical services. To see if your procedure is covered, contact us. Your private health information is just that private. Preventive & screening services, Medicare.gov, last accessed June 10, 2022. Copyright 2022 Employer Direct HealthcareAll Rights Reserved. Out-of-pocket costs may be greater if you visit a dentist who does not participate in the network. Metlife will not pay Dental Insurance benefits for charges incurred for: Alternate Benefits For some conditions, such as end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS), you could be eligible for Medicare before you turn 65.13. You are always free to select the dentist of your choice. Inpatient (Precertification is required): $350 per admission. It can include Durable Medical Equipment (DME), mental healthcare or ambulance services.2 Preventive care services are health treatments that prevent illness or detect problems at an early stage, like flu shots or cancer screenings.3, There are some things Original Medicare wont cover. Consult your doctor before beginning any new diet or exercise regimen. }4Q2L_L 0fI\l!AN7za|*_)2:lU2_kciTX*R:N%` c8B=3 Alternatively, a Medicare Advantage plan often provides comprehensive vision coverage, plus cataract surgery without out-of-pocket coinsurance costs.". 0000418667 00000 n Yes. However, Medicare doesnt cover routine hearing exams, hearing aids or fittings.7. Tax Center Malini Ghoshal, What You Need to Know About Medicare Prescription Drug Plans (Part D), Healthline, last accessed June 10, 2022. It has less visits to physical, speech and occupational therapies than HIP Plus. For example, if youre still working and covered by your employer or your spouses employer sponsored health coverage, you may be able to wait. Delaware Topics 0000019705 00000 n You can make monthly payments by monthly bank draft (ACH) or pay for the entire year via credit card payment. Fair and simple terms We pay a fair, transparent rate for cases and streamline reimbursement, decreasing your administrative burden. RSS Feeds, Make Negotiated fees typically range from 15-45% below the average fees charged in a dentists community for the same or substantially similar services. Privacy Policy Starting January 1, 2018, HIP State Basic and HIP State Plus will cover members age 21 to 64. "L @Zd X$9RAC~yGz3)fjaPk !e E57 Hln8 ``:w0@6Cfmu ] We recommend that you request a pre-treatment estimate for services in excess of $300. This Coverage Policy addresses bariatric surgery and procedures for the treatment of morbid obesity. Effective July 1, 2023, bariatric surgery coverage will be available exclusively through the SurgeryPlus benefit. The surgery and any facility costs will be 100% covered under your SurgeryPlus benefit. %PDF-1.4 % Locations Directory endstream hbbd```b``+@$}D Take your bill (s) to your State Farm agent's office. When youre making decisions about buying a plan or using your benefits, an SBC can be a useful tool to help you compare costs and understand coverage options. The following services that are in progress while coverage is in effect will be paid after the coverage ends, if the applicable installment or the treatment is finished within 31 days after individual termination of coverage: Completion of a prosthetic device, crown or root canal therapy. By packaging surgical expenses into one simple, bundled rate, SurgeryPlus is able save money for you and the State of Florida. Wearing a swimsuit after a mastectomy can be a transition. The requirements needed for surgery, including any pre-operative tests, screenings, evaluations, and post-operative care will continue to be covered under your Aetna or Highmark Delaware non-Medicare health plan. Certain claim and network administration services are provided through Vision Service Plan (VSP), Rancho Cordova, CA. Mon-Fri, 8:30am-5:00pm (CT). startxref In some cases, your association and/or the plan administrator may incur costs in connection with providing oversight and administrative support for this sponsored plan. Learn more aboutsavings and spending accounts. Many Medicare Advantage plans, however, do include coverage for routine dental, vision and hearing care, including glasses and hearing aids. The cost of cataract surgery not only depends on the equipment used and the IOL implanted, but on the skill of the surgeon, your overall health, and where you live in the country. This assures State of Delaware Aetna and Highmark Delaware members will have access to surgeons and facilities that meet strict SurgeryPlus credentialing guidelines, leading to the highest quality care possible. However, if you choose a non-participating dentist, your out-of-pocket costs may be higher. Read your certificate of insurance for details on plan benefits, limitations, and exclusions. The service categories and plan limitations shown below represent an overview of the plan benefits. SurgeryPlus is separate from your health plan and has its own network of high-quality providers. 0000012970 00000 n <<7C167570AC52504DB41418C8CABC0A04>]/Prev 422895/XRefStm 1266>> Generally, Medicare Part A (also known as hospital insurance) can cover inpatient hospital care, nursing facility care, nursing home care, hospice care and home healthcare.1, Medicare Part B (also known as medical insurance) offers coverage for medically necessary and preventive care services. What is the SurgeryPlus benefit? For the Plus Size Queens. Home. These savings are shared with the member through financial incentives and members will not be required to pay a copay, deductible, or coinsurance for services provided through SurgeryPlus. Outpatient facility care: 35% of our allowance . Also, your doctor will need to certify that you need certain eligible in-home services. The SBC was created to make it easier to compare and shop for health plans. 0000019224 00000 n An important note: If you want coverage for prescription drugs, you must sign up as soon as youre eligible, unless you have whats called creditable prescription drug coverage elsewhere. Adjustable straps allow for a better, customized fit. Learn more about a Summary of Benefits and Coverage, also commonly referred to as an SBC. 89 0 obj <> endobj Copyright 2023 Member Benefits. hb``P```e```5c@L@q EP0 endstream endobj 124 0 obj <>/Filter/FlateDecode/Index[5 84]/Length 22/Size 89/Type/XRef/W[1 1 1]>>stream We cover the most expensive costs associated with your surgery so you'll pay less for your procedure. Child(ren)s eligibility for dental coverage is from birth up to age 26. 89 37 such as Spine, General Surgery, Genitourinary, Orthopedic, Ear, Nose & Throat, Cardiac, GI, and Pain Management. 0000011564 00000 n Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. When enrolling you may choose to also cover your spouse, domestic partner, and/or children up to age 26. 0000024943 00000 n HIP Plus is the plan for the best value.HIP Plus provides health coverage for a low, predictable monthly cost. It all depends on your policy. You and your dentist will receive a benefit estimate for most procedures while you are still in the office. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan. Elected Officials endstream endobj 251 0 obj <. This type of surgery is only used for people who are very overweight and have not been able to lose weight with diet and exercise. 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; Duplicate prosthetic devices or appliances; Replacement of a lost or stolen appliance, Cast Restoration, or Denture; and. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. Medicare Advantage plans are provided by private companies with approval from Medicare. All health plan companies are required to provide an SBC for each of their different plans. Filing a health claim. So you may be responsible for any difference in cost between the dentists fee and your plans benefit payment. Negotiated fees may extend to services not covered under your plan and services received after your plan maximum has been met, where permitted by applicable state law. 273 0 obj <>/Filter/FlateDecode/ID[<0FC6C6833B2C26439F46B854E028A8C8>]/Index[250 36]/Info 249 0 R/Length 110/Prev 207371/Root 251 0 R/Size 286/Type/XRef/W[1 3 1]>>stream Updated 08/29/2019 . 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; Services for which covered person would not be required to pay in the absence of Dental Insurance; Services or supplies received by covered person before the Dental Insurance starts for that person; Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate); 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: Services or appliances which restore or alter occlusion or vertical dimension; Restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease; Restorations or appliances used for the purpose of periodontal splinting; Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco; Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss; Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work; covered under any workers compensation or occupational disease law; covered under any employer liability law; for which the Policyholder of the person receiving such services is not required to pay; or. Many Medicare Advantage plans include prescription drug coverage, in addition to all the benefits provided by Original Medicare Part A and Part B. 866-855-1212 to request a claim form. General Assembly Blue Distinction Centers for Substance Use Treatment and Recovery aims to improve patient outcomes and value by focusing on providers across the full continuum of care who deliver and facilitate treatment for substance use disorder, including opioid use disorder. What Part B covers, Medicare.gov, last accessed June 10, 2022. 1XQg&.9mE#(Tq& <> Theres a lot of information in an SBC. 0 Does Medicare Cover Pre-existing Conditions? Medicare.com, last accessed June 10, 2022. 0000005131 00000 n Consistent with federal law effective 1/1/98, the Cigna national maternity policy includes coverage for 48 hours of hospitalization following a normal vaginal delivery and 96 hours following an uncomplicated Caesarean section. A reminder that the SBC is only a summary. All services defined in your group dental benefits plan certificate are covered. With our nationwide network of top surgeons, our Care Advocates help you find an excellent provider as close to home as possible who is highly experienced in the specific procedure you need. This information is provided for educational purposes only. How can we make this page better for you? 1026 0 obj Policy form GPNP99. Bariatric surgery is surgery to help you lose weight. You or your dependent use SurgeryPlus to receive a preoperative to post-operative bundled surgical service; SurgeryPlus validates that you or your dependent received the service; and. 0000001036 00000 n Coverage terminates when your membership ceases, insurance ceases for your class, when your dental contributions cease or upon termination of the group policy by the Policyholder or MetLife. For example, rather than paying separately for the surgeon, facility, anesthesiologist, and radiologist, SurgeryPlus negotiates one bundled rate. Medicare covers hospice care if the following conditions are met: Medicare does help cover some in-home health services, including: To be eligible, you must be under the care of a doctor and treated under a plan of care that is monitored and reviewed by your doctor. Complete and submit the form and well be in touch soon. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. But treatment for chronic eye conditions like cataracts or glaucoma may be covered if your doctor considers it to be medically necessary.12. They help you find a great doctor for your procedure, schedule your procedure appointments, make travel reservations (if travel is required), transfer your medical records, and coordinate all your surgery bills. Franchise Tax If you need cataract surgery in both eyes . In . Coverage includes access to our network of excellent surgeons, consults and appointments with your SurgeryPlus provider, anesthesia, the procedure and facility (hospital) fees. xref 0000392965 00000 n Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. What Part A covers, Medicare.gov, last accessed June 10, 2022. Medicare pays 80% of the cost of traditional cataract surgery, which would be covered by Medicare Part B. 10 frequently asked questions about Medicare plans, Deductibles for Medicare Part A and Part B. 1 Sturti / Getty Images Coverage Varies by Insurer Each health plan is different. Inpatient hospital: $450 per admission copay for unlimited days, plus 35% of our allowance. 0000377893 00000 n Adjusting to the physical changes post-surgery can be difficult, and finding the right mastectomy bra is one of the most important steps in the process. Please contact MetLife or Member Benefits, your plan administrator at 1-800-282-8626 for costs and complete details. Pick the option that's best for you. It also includes more benefits like dental, vision, or chiropractic.With HIP Plus, you do not have copays when you visit the doctor, fill a prescription or go to the hospital for an emergency.On average, HIP Plus members spend less money on their health care . Medicare Advantage plans may offer coverage for vision, hearing, dental and wellness services. Your Care Advocate will provide you with personalized support, helping you to understand your benefit, find you excellent care, coordinate any consults and appointments with your SurgeryPlus surgeon and make sure you feel informed every step of the way. It requires doctors and facilities to meet strict credential guidelines leading to the highest quality care possible. Your medical insurance may also pick up the cost in full or part for medically-related . To provide and maintain this valuable membership benefit, MetLife reimburses the association and/or the plan administrator for these costs. Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. 0000009101 00000 n International dental travel assistance services are administered by AXA Assistance USA, Inc. AXA Assistance is not affiliated with MetLife or any of its affiliates, and the services they provide are separate from the benefits provided by MetLife. 0000000016 00000 n You may choose to share the information with your doctor and other medical professionals. 1096 0 obj Please use this access code on website: surgeryplus. Licensed Humana sales agents are available daily, 8a.m. 8 p.m. We suggest you discuss treatment options with your dentist before services are rendered, and obtain a pre-treatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. Looser styling flatters while cleverly camouflaging around your middle. Policy number TS 05343606-G (High plan) Coverage is provided under a group insurance policy (Policy form GPNP99) issued by MetLife. Alternatively, a Medicare Advantage plan often provides comprehensive vision coverage, plus cataract surgery without out-of-pocket coinsurance costs." Medicare pays 80% of the cost of traditional cataract surgery, which would be covered by Medicare Part B. Yes. This symbol denotes a Web Page. Vision benefits are underwritten by Metropolitan Life Insurance Company, New York, NY (MetLife). Each company is a separate entity and is not responsible for another's financial or contractual obligations. Medicare will not pay for 24-hour in-home care or meals delivered to you at home. SurgeryPlus offers a variety of medical procedures, including the following: Terms and Conditions | Privacy Statement | Accessibility Statement | Sitemap, Monthly Webinars / Educational YouTube Videos, Making plan changes with a Qualifying Status Change (QSC) Event. The inclusion of a code does not imply any right to . You may need to exhaust your personal resources on medical care before you are eligible. SurgeryPlus notifies that you or your dependent earned the reward. This group plan is made available to through membership in the American Association of Business Networking (ABN). Austin, TX 78735 Or Reach Us at. Please note: If you are covered under the State of Delaware Group Health Insurance Plan as secondary, refer to the SurgeryPlus plan document for details on bariatric coverage. The SurgeryPlus Difference We allow you to focus on practicing medicine and caring for patients. To get all the details, youll want to look at complete health plan documents. Generally, Medicare Part B covers cataract surgery because it's usually performed in an outpatient clinic, and most people won't require a hospital stay afterward. 9l J'X:50e0l`} }U,,Q`lam[5-0f`MVe` received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital; Services covered under other coverage provided by the Policyholder; Services for which the submitted documentation indicates a poor prognosis; The following when charged by the Dentist on a separate basis: infection control such as gloves, masks, and sterilization of supplies; or. Will Medicare Cover LASIK Eye Surgery? Medicare.org, last accessed June 10, 2022. Most plans cover the entire cost of preventive care, plus a portion of the cost after you meet your deductible for other procedures. VSP is not affiliated with Metropolitan Life Insurance Company or its affiliates. Original Medicare generally covers most pre-existing conditions. 0000001266 00000 n Effective July 1, 2023, all bariatric surgeries will be required to be completed through the SurgeryPlus benefit and performed by a surgeon in the SurgeryPlus network. 0000024865 00000 n Please contact MetLife or Member Benefits, your plan administrator at 1-800-282-8626 for costs and complete details. Policy number TS 05343606-G (High plan) Policy number 5343606-1-G (Low plan) Metropolitan Life Insurance Company, 200 Park Avenue, New York, NY 10166. Facilitate and consolidate your payments. *Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums. Coverage will be considered under your out-of-network benefits. Scuba Certification; Private Scuba Lessons; Scuba Refresher for Certified Divers; Try Scuba Diving; Enriched Air Diver (Nitrox) When will my medical insurance cover oral surgery? 285 0 obj <>stream 988 0 obj Refer to the customer's benefit plan document for coverage details. It does not cover bariatric surgery or jaw care (TMJ). The State of Delaware is an Equal Opportunity employer and values a diverse workforce. 0000025231 00000 n What's not covered by Part A & Part B? Medicare.gov, last accessed June 10, 2022. <>stream This communication does not guarantee benefits and does not indicate all services received will be covered by your plan. Please remember to hold on to all receipts to submit a dental claim. State Regulations Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. Enter your ZIP code below to see plans with their premiums, copays, and participating doctors and pharmacies. 1. 0 Pre-/postnatal professional care: 35% of our allowance . Learn more about the ABN. Text Size Smaler, Make Text Size Continuous Glucose Monitors (CGMs)examples include Dexcom and Libre. Prescription drug planscalled Medicare Part Dare only available through private companies like Humana. You consent to receiving palliative care to make you comfortable versus care to try to cure your illness. Confirm your coverage before you commit to a procedure you're unsure about. This program utilizes the MetLife PDP Plus Network of participating dentists. What is Medicare Part C? U.S. Department of Health & Human Services, last accessed June 10, 2022. hbbd```b``f+A$S$d@$&},L`1]`*z3`] rO o bHHj@&{:.a`$ S SurgeryPlus offers surgical procedures that are covered under the State Group Health Insurance Program, but is different from your health insurance plan because the healthcare services are "bundled" together. Whats a Summary of Benefits and Coverage? American Airlines manages employee and retiree health benefits. Eleesha Lockett, Does Medicare Cover Plastic Surgery? Healthline, last accessed June 10, 2022. 0 0000015806 00000 n Wearing a Suit After a Body-Altering Surgery. You can choose whether or not to use SurgeryPlus for your surgical procedures. Dentists may submit your claims for you which means you have little or no paperwork. SurgeryPlus is a supplemental benefit for non-emergency surgeries which provides high-quality care, concierge-level member service and lower costs. Administrative services provided by United HealthCare Services, Inc. or their affiliates. endobj Jacksonville, FL 32256 TE 6Uz A$& &`5= X7"yH: wd`^+H(`q] DF9qt The group policy terminates for non-payment of premium and may terminate if participation requirements are not met or if the Policyholder fails to perform any obligations under the policy. This website and phone number are for use by dental professionals only. Personal Income Tax Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. As a member of Humana, you can receive up to 15 percent off standard LASIK pricing (and 5 percent off promotional pricing) at specified in-network providers. endobj Negotiated fees are subject to change. (Portal access Code: surgeryplus). Coverage includes access to our network of excellent surgeons, consults and appointments with your SurgeryPlus provider, anesthesia, the procedure and facility (hospital) fees. HVn7}Wt)A87HPV$(YXF;3as=sfj'O&y>=zF_Gmlr:v1z5`:A1suhMFY}r0_&o^w]vw%'o':~u>)|]!6nRBki;L}h0y^'#cCmJJc State Agencies Filing a health insurance claim is simple and can be done in one of two ways. 0000014251 00000 n Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment.