Page 14 - ABM 2021 Benefit Guide MGT HI
P. 14
DENTAL BENEFITS
Whether or not you join the medical plan, you may
Dental PPO enroll in dental coverage administered through
ABM ofers team members three dental plans. You MetLife or Hawaii Dental Service. ABM has made
can ind out how a dental procedure will be covered in
advance. Ask your provider for a predetermination of some modernization changes to the MetLife dental
beneits to estimate plan coverage and out-of-pocket beneits. Please see below for an overview of the
costs. plan designs. The percentages shown in this table
With the MetLife dental plans you can receive care are the amounts the plan pays.
from any provider; however, you will receive a higher
level of beneit if you stay in-network. Even though the Premium Dental Standard Dental
reimbursement percentages are the same for in- and Calendar Year Deductible In-Network In-Network
out-of-network services, out-of-network providers do Individual $25 $50
not agree to discounted fees which can make out- Family $75 $150
of-network usage more expensive. Out-of-network Calendar Year Maximum
charges are subject to reasonable and customary $3,000 per person $1,500 per person
charges. Coinsurance
Preventive—Type A 100% no deductible 100% no deductible
Hawaii Dental Service Basic—Type B 70% after deductible 70% after deductible
Major—Type C
50% after deductible 50% after deductible
In-Network Orthodontia
Calendar Year Deductible Coinsurance 50% after deductible 50% after deductible
Individual $25 Lifetime Maximum $2,500 $1,000
Family $75 Beneit Applies To Adults and children Adults and children
Visits and Exams
Calendar year maximum Limitations 2 per year 2 per year
$1,200 Prophylaxis, including 100% no deductible 100% no deductible
Coinsurance Scaling and Polishing
Preventive 0% no deductible Fluoride 100% no deductible 100% no deductible
Basic You pay approximately 30% Limitations 2 per year 2 per year
Major You pay approximately 50% Sealants 100% no deductible 100% no deductible
Limitations
1 per every 3 years 1 per every 3 years
Orthodontia Not covered to 14 to 14
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel Crowns 70% after deductible 70% after deductible
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
To look for a provider to learn more about this coverage; visit:
metlife.com/mybeneits.
14 2021 Benefits Enrollment
Whether or not you join the medical plan, you may
Dental PPO enroll in dental coverage administered through
ABM ofers team members three dental plans. You MetLife or Hawaii Dental Service. ABM has made
can ind out how a dental procedure will be covered in
advance. Ask your provider for a predetermination of some modernization changes to the MetLife dental
beneits to estimate plan coverage and out-of-pocket beneits. Please see below for an overview of the
costs. plan designs. The percentages shown in this table
With the MetLife dental plans you can receive care are the amounts the plan pays.
from any provider; however, you will receive a higher
level of beneit if you stay in-network. Even though the Premium Dental Standard Dental
reimbursement percentages are the same for in- and Calendar Year Deductible In-Network In-Network
out-of-network services, out-of-network providers do Individual $25 $50
not agree to discounted fees which can make out- Family $75 $150
of-network usage more expensive. Out-of-network Calendar Year Maximum
charges are subject to reasonable and customary $3,000 per person $1,500 per person
charges. Coinsurance
Preventive—Type A 100% no deductible 100% no deductible
Hawaii Dental Service Basic—Type B 70% after deductible 70% after deductible
Major—Type C
50% after deductible 50% after deductible
In-Network Orthodontia
Calendar Year Deductible Coinsurance 50% after deductible 50% after deductible
Individual $25 Lifetime Maximum $2,500 $1,000
Family $75 Beneit Applies To Adults and children Adults and children
Visits and Exams
Calendar year maximum Limitations 2 per year 2 per year
$1,200 Prophylaxis, including 100% no deductible 100% no deductible
Coinsurance Scaling and Polishing
Preventive 0% no deductible Fluoride 100% no deductible 100% no deductible
Basic You pay approximately 30% Limitations 2 per year 2 per year
Major You pay approximately 50% Sealants 100% no deductible 100% no deductible
Limitations
1 per every 3 years 1 per every 3 years
Orthodontia Not covered to 14 to 14
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel Crowns 70% after deductible 70% after deductible
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
To look for a provider to learn more about this coverage; visit:
metlife.com/mybeneits.
14 2021 Benefits Enrollment
