Page 49 - 2022 MLB Umpire Benefit Guide Flipbook 1

MLB League-Wide Insurance Program
Plan and Summary Plan Description

plan status can be directed to the Office of the Commissioner’s Human Resources
Department, 1271 Avenue of the Americas, NewYork, NY,10020, telephone:212-931-7852.
You may also contact the Employee Benefits Security Administration, U.S. Department of
Labor at1-866-444-3272or www.dol.gov/ebsa/healthreform. Thiswebsite has a table
summarizing which protections do and do not apply to grandfathered health plans.

Dental Option Offered:

PPO Option-This program generally provides100% of costs up to the maximum allowable charge
for in-network Type A Services (preventive services), 90% of costs up to the maximum allowable
chargefor in-network Type BServices ( basic restorativeservices), 60% of costs up to the maximum
allowable charge for in-network Type CServices (major restorativeservices),and50% of costs up to
the maximum allowable charge for in-network Type DServices (orthodonticservices). Type Band
Type CServices are covered after a $50 individual or $150 family deductible. Type A,Type B, and
Type CServices are subject to a $3,000 annual limit per person. Type D(orthodontic) Services are
only covered for children under age 19 and are subject to a $3,000 lifetime limit per person. This
program also generally provides100% of costs up to the reasonable and customary charge for out-of-
network Type A Services, 80% of costs up to the reasonable and customary charge for out-of-
network Type B Services, 50% of costs up to the reasonable and customary charge for out-of-
network Type C Services, and 50% of costs up to the reasonable and customary charge for out-of-
network Type D (orthodontic) Services. For residents of Louisiana, Mississippi and Texas, this
program generally provides100% of costs up to the reasonable and customary charge (as defined in
the benefit booklet) for out-of-network Type A Services, 90% of costs up to the reasonable and
customary charge for out-of-network Type B Services, 60% of costs up to the reasonable and
customary charge for out-of-network Type C Services, and 50% of costs up to the reasonable and
customary charge for out-of-network Type D (orthodontic) Services. Out-of-network coverage is
available based on the reasonable and customary charge rather than the maximum allowable charge.
This means that if an out-of-network dentist performs a covered service, you will be responsible for
paying the deductible, any part of the reasonable and customary charge that is not covered, and any
amount charged by the out-of-network dentist in excess of the reasonable and customary charge.
Please refer to the benefits booklet for more information.

COBRA Contact:
Human Resources
1271 Avenue of the Americas
New York, NY 10020
Telephone: 212-931-7852

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