Citi Benefits Handbook
How the Plan Works
The MetLife PDP allows you to receive care from any dentist. At the time you need dental care, you decide whether to visit a PDP dentist or go to a dentist outside the PDP network. The Plan provisions (deductibles, coinsurance and annual and lifetime maximums) will be the same whether or not your dentist is a PDP provider. However, using preferred dentists can reduce your out-of-pocket costs.
Annual Deductible and Maximum
Before benefits can be paid in a calendar year, you and/or your covered dependent(s) must meet the $50 individual or $150 maximum family deductible. The deductible does not apply to preventive and diagnostic services. However, the deductible does apply to basic, major and orthodontia services.
You can meet the family deductible as follows:
- Up to three people in a family: Each member must meet the individual deductible.
- Four or more people in a family: Expenses can be combined to meet the family deductible. However, no one person can apply more than the $50 individual deductible toward the $150 family deductible.
You and/or your covered dependent(s) have an annual maximum benefit of $3,000 per person (excluding orthodontia). The annual maximum benefit does not apply to preventive and diagnostic services. However, the annual maximum benefit does apply to basic and major services. In addition, a separate lifetime maximum of $3,000 per person applies to orthodontia treatment.
After you have met the deductible, the MetLife PDP reimburses covered charges for out-of-network dentists at a percentage of the maximum allowed amount (MAA) charges. The MetLife PDP determines the MAA based on the amounts charged for a specific service by most dentists in the same geographic area. For network charges, the reimbursement is based on a percentage of the fees negotiated with the network dentists.
A dental charge is incurred on the date the service is performed or the supply is furnished. However, there are times when one overall charge is made for all or part of a course of treatment. In this case, the "completion date" is considered the date the charge is incurred. The claim will be paid in a lump sum (excluding orthodontia). For example, the completion date is considered for:
- Root canal therapy as the date the pulp chamber was closed;
- A crown as the date the tooth was completed for the crown;
- Partial and complete dentures as the date of completion; and
- Fixed bridgework as the date the abutment teeth were completed for the bridge.
Orthodontic payments are paid differently.
Coverage for New Orthodontic Work
The Plan pays 50% of the expense submitted. For example, if the orthodontic expense submitted is $5,000, the Plan will pay the benefit as follows:
Coverage for orthodontic appliance: MetLife will pay an initial appliance component (sometimes referred to as the "banding" fee) based on 20% of the submitted expense, at the 50% coinsurance level:
Coverage for monthly payments:
- $5,000 - $1,000 = $4,000;
- $4,000 ÷ 24 months = $167 × 50% benefit = $84;
- Therefore, the monthly payment will be $84.
A monthly payment of $84 will be made over the course of treatment, paid each treatment quarter. The first payment will be based on 20% of the expense to cover the appliance fee. The remaining expense will be spread over the expected length of treatment. In this example, that is 24 months or eight quarterly payments. Orthodontic benefits are subject to the calendar-year deductible and the $3,000 lifetime orthodontia maximum. In this example, assuming the annual deductible has been met, the total amount paid will be $2,516.
Coverage for Orthodontic Work in Progress
The MetLife PDP pays 50% coinsurance, after the annual deductible is met, up to a $3,000 lifetime orthodontia maximum. Orthodontia benefits paid since January 1, 2004, under the MetLife and Delta Dental Citi-sponsored plan (the Delta Plan is no longer available) will count toward the lifetime orthodontia maximum under the MetLife PDP.
Before You Receive Care
Before you receive certain dental services, you are advised to discuss the treatment plan with your dentist to determine what is covered by the MetLife PDP Plan.