endstream endobj 97 0 obj <>stream Pick the option that's best for you. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. This symbol denotes a PDF Document. 6 Original Medicare may even pay for corrective lenses if you have surgery to implant an intraocular lens (IOL). General Assembly <>stream "_P^)J^:+&!nI-eMNYrVY;QU&+,SUdTVvSN(GTDS o5q_H\%lqbF$M2Q::=x?c}Efl 2"PwyOP# 3V&$b$E7TXI!"?k* NZOLizJT5A7a Xk56C*I~EOv {)Z` YFJ#i'O>4@6.\7=dBkwR)K@kJ^.|xs-v(\irQJhpQ-[":wwT%9KBU2hNU^ 6/En!`}#Yrud9,/R Malini Ghoshal, What You Need to Know About Medicare Prescription Drug Plans (Part D), Healthline, last accessed June 10, 2022. An estimated cost of cataract surgery may be*: In a surgery center or clinic, the average total cost is $977. Pre-/postnatal professional care: 35% of our allowance . It is not to be used for medical advice, diagnosis or treatment. Assign you a personal care coordinator to offer one-on-one guidance and support as you prepare for, undergo and recover from surgery. 0000000016 00000 n Benefits are subject to change upon agreement between Metropolitan Life Insurance Company and the participating organization. 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. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Consult your doctor before beginning any new diet or exercise regimen. %PDF-1.4 % Premiums and the list of covered drugscalled a formularywill vary by plan.6. Mastectomy surgery is a significant life event for many people. You can use the Glossary of Health Coverage and Medical Terms, also called a Uniform Glossary to get clear, simple answers about what terms mean. 866-855-1212. This is a voluntary benefit available to you if you're enrolled in the Core, Standard, Plus or High Cost Coverage medical option. The time a mother and baby spend in the hospital after delivery is a medical decision. 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. For example, rather than paying separately for the surgeon, facility, anesthesiologist, and radiologist, SurgeryPlus negotiates one bundled rate. A mastectomy bra can provide comfort, support, and security to an individual as they become accustomed to their new normal. 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 Some general conditions to receive coverage from United Healthcare requires that you meet the following criteria: Have a body mass index over 40 OR. 0000024943 00000 n endstream endobj 90 0 obj <>/Metadata 3 0 R/OpenAction 91 0 R/Pages 2 0 R/StructTreeRoot 5 0 R/Type/Catalog/ViewerPreferences<>>> endobj 91 0 obj <> endobj 92 0 obj >/PageTransformationMatrixList<0[1.0 0.0 0.0 1.0 0.0 -396.0]>>/PageUIDList<0 878>>/PageWidthList<0 612.0>>>>>>/Resources<>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 93 0 obj <> endobj 94 0 obj <> endobj 95 0 obj [/Indexed/DeviceRGB 250 104 0 R] endobj 96 0 obj <>stream State Regulations What Part A covers, Medicare.gov, last accessed June 10, 2022. This document presents the majority of services within each category, but is not a complete description of the plan. Some types of surgery also change the connection between your stomach and intestines. 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. Most plans cover the entire cost of preventive care, plus a portion of the cost after you meet your deductible for other procedures. 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. Medicare will only provide coverage through suppliers who participate in the Medicare program.10, Services that are not considered medically necessary are generally not covered by Medicare Part A or Part B. 0000010311 00000 n 0000005180 00000 n lbSy cost of cataract surgery with medicare. 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. This program utilizes the MetLife PDP Plus Network of participating dentists. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1-312-356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist. You can also go through the SurgeryPlus member portal. Have a body mass index over 35 with severe comorbidity. Negotiated fees are subject to change. 0000379543 00000 n This information is provided for educational purposes only. However, this depends on the specific type of surgery you need, your dental plan, and your level of coverage. Copyright 2022 Employer Direct HealthcareAll Rights Reserved. Coverage includes access to our network of excellent surgeons, consults and appointments with your SurgeryPlus provider, anesthesia, the procedure and facility (hospital) fees. Out-of-pocket costs may be greater if you visit a dentist who does not participate in the network. It also doesnt cover help for whats called activities of daily living, like bathing, getting dressed, using the toilet, eating or moving from place to place within your home.9. Effective July 1, 2023, bariatric surgery coverage will be available exclusively through the SurgeryPlus benefit. If the information online is inconsistent with the Plan Documents, the Plan Documents will govern. 0000001266 00000 n Does Medicare Cover Pre-existing Conditions? Medicare.com, last accessed June 10, 2022. If it contains a form, you can fill it out online and submit it. A dental plan may cover routine office visits, fillings, crowns, root canals, oral surgery, periodontics, orthodontics, or bridges and dentures. 1096 0 obj You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plans reimbursement for those services, and your out-of-pocket expense. Call our Health Response Center at. These rules determine the order in which the plans will pay benefits. 0000001036 00000 n If you need cataract surgery in both eyes . When it comes to Medicare, the question we hear most often after What does it cost? is, What does it cover?. You can make monthly payments by monthly bank draft (ACH) or pay for the entire year via credit card payment. This surgery makes the stomach smaller. Please Note: Additional information about this benefit change will be posted as it becomes available and before the July 1, 2023 effective date. 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. Pre-authorization will still need to be submitted by your provider to SurgeryPlus before the surgery is scheduled. If you qualify for it, Medicaid, which is administered by states under federal guidelines, may cover nursing home care. You earn the reward once the following occurs: The reward will then be credited to the savings and spending account of your choice. When you already have a health plan, youll get an SBC automatically at certain times: Even though an SBC is made to make it easier to understand health plan information, sometimes the terms in them can be confusing. Learn more about COVID-19 and the vaccine from the Division of Public Health, Learn about your benefits and resources for Behavioral Health & Emotional Wellbeing More Info. Many Medicare Advantage plans also provide prescription drug coverage (also known as Part D).5, Original Medicare does not include coverage for prescription drugs, but you can buy a stand-alone prescription drug plan to help manage your drug costs. Original Medicare generally doesnt cover the cost of a nursing home, assisted living or long-term care facility. Privacy Policy 0 This webpage is provided for summary purposes only and is not a complete description of the plan benefits, limitations, and exclusions. Please review the plan summaries for summarized information and your certificate of insurance for detailed information about your plan benefits. Generally, most vision, dental and hearing services are not covered by Medicare Parts A and B. Other services not covered by Medicare Parts A and B include:4, Medicare Part C is also known as Medicare Advantage. It requires doctors and facilities to meet strict credential guidelines leading to the highest quality care possible. %%EOF 0000004536 00000 n Members will pay nothing out of pocket for bariatric surgery; however, financial incentives do not apply. Alternatively, a Medicare Advantage plan often provides comprehensive vision coverage, plus cataract surgery without out-of-pocket coinsurance costs.". Savings from enrolling in a dental benefits plan will depend on various factors, including how often members visit participating dentists and the cost for services rendered. Please remember to hold on to all receipts to submit a dental claim. (Due to contractual requirements, MetLife is prevented from soliciting certain providers.) Surgical Coverage Surgery Surgery Medicare covers many medically necessary surgical procedures. The surgery and any facility costs will be 100% covered under your SurgeryPlus benefit. This symbol denotes a Web Page. 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. NCD for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (100.1) and NCD for Surgery for Diabetes (100.14) for coverage guideline. Coverage is provided under a group insurance policy (Policy form GPNP99) issued by MetLife. 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. Your SurgeryPlus Care Advocate will provide you one-on-one, personalized help each step of the way. At time of enrollment, you will choose how you want to pay. We strongly encourage and seek out a workforce representative of Delaware including race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression. . 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. 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. Consult your healthcare provider if you have questions or concerns. All services defined in your group dental benefits plan certificate are covered. But treatment for chronic eye conditions like cataracts or glaucoma may be covered if your doctor considers it to be medically necessary. Your costs in Original Medicare For surgeries or procedures, it's hard to know the exact costs in advance. 0000001651 00000 n 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. Administrative services provided by United HealthCare Services, Inc. or their affiliates. 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. 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 Help Center (Based on internal analysis by MetLife. You may enroll for membership in the ABN directly through the ABN website or during your dental enrollment. SurgeryPlus negotiates all costs before the surgery, so youll pay a single rate for all associated surgical charges, and any bills will come directly from SurgeryPlus. This website and phone number are for use by dental professionals only. Examples of procedures covered are hernia repair, hysterectomy, colonoscopy, tendon release, spine injections and fusions, knee replacements, and many more. 0 Coverage includes access to our network of excellent surgeons, consults and appointments with your SurgeryPlus provider, anesthesia, the procedure and facility (hospital) fees. Overview . SurgeryPlus notifies that you or your dependent earned the reward. Vision benefits are underwritten by Metropolitan Life Insurance Company, New York, NY (MetLife). 0000019224 00000 n 0000378718 00000 n Our licensed Humana sales agents are available to help you select the coverage that best meets your needs. 250 0 obj <> endobj Preventive & screening services, Medicare.gov, last accessed June 10, 2022. Once your policy takes effect, you can still add or remove dependents to your coverage once per year on the group plan anniversary date of Jan 1 or if you have a qualifying event such as marriage, divorce, birth of a child, and spouses termination of employment. An explanation of whats not covered and/or the limits on coverage, Information on costs you might have to pay like deductibles, coinsurance and copayments, Coverage examples, including how coverage works in the case of a pregnancy or a minor injury. 0000025231 00000 n 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. You sign a consent form to receive hospice care instead of other Medicare-covered treatments for your terminal condition. 0000014251 00000 n If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental.com, or call 1-866-PDP-NTWK for an application. When enrolling you may choose to also cover your spouse, domestic partner, and/or children up to age 26. 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. Visit ESPN for the game videos of the Brooklyn Nets vs. Boston Celtics NBA basketball game on March 3, 2023 SurgeryPlus is separate from your health plan and has its own network of high-quality providers. Local Coverage Determinations (LCDs)/Local Coverage Article (LCAs) exist and compliance with these policies is required where applicable. Many Medicare Advantage plans include prescription drug coverage, in addition to all the benefits provided by Original Medicare Part A and Part B. %%EOF startxref Filing a health insurance claim is simple and can be done in one of two ways. Benefit coverage for health services is determined by the member specific benefit plan document and applic able laws that may require coverage for a specific service. This Coverage Policy addresses bariatric surgery and procedures for the treatment of morbid obesity. Even though its meant to make the information easier to understand, it can seem like a lot at first. xref 0000377893 00000 n Your medical insurance may also pick up the cost in full or part for medically-related . 3 You must be the contract holder or spouse, 18 or older, on a Standard or Basic Option Plan to earn incentive rewards. Elected Officials For specific LCDs/LCAs, refer to the table for 0000015692 00000 n Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. (Portal access Code: surgeryplus). 555 17th Street, Suite 2050 | Denver, CO 80202, 2023 CEBT :: CEBT is administered by WTW, When you use SurgeryPlus, CEBT will potentially waive your Out-of-Pocket costs (i.e. The SBC was created to make it easier to compare and shop for health plans. Mobile Apps endobj Rest easy knowing you can afford the surgery you need, HDHP Plans will require a reduced deductible to be met first. such as Spine, General Surgery, Genitourinary, Orthopedic, Ear, Nose & Throat, Cardiac, GI, and Pain Management. Business First Steps, Phone Directory The complete provisions of the plans are set forth in the Plan Documents and Summary Plan Description. This symbol denotes a PDF Document. Medicare Part B benefits cover 80% of the Medicare-approved amount for cataract surgery. Licensed Humana sales agents are available daily, 8a.m. 8 p.m. Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166. Find out which Humana plans include your doctors and cover the medications you take now to help you estimate your costs. Theres a lot of information in an SBC. Also, your doctor will need to certify that you need certain eligible in-home services. The primary result of . You pay 20% of the Medicare Part B copay plus any out-of-pocket costs such as your deductible, medication costs and physician fees. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. To connect with SurgeryPlus today, call 833-709-2445. Fair and simple terms We pay a fair, transparent rate for cases and streamline reimbursement, decreasing your administrative burden. Rates are subject to change and depend on geographic area. 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. How can we make this page better for you? What is the SurgeryPlus benefit? Medicare will not pay for 24-hour in-home care or meals delivered to you at home. The State of Delaware is an Equal Opportunity employer and values a diverse workforce. You can choose whether or not to use SurgeryPlus for your surgical procedures. 9l J'X:50e0l`} }U,,Q`lam[5-0f`MVe` Adjustable straps allow for a better, customized fit. Yes. The inclusion of a code does not imply any right to . Thats because its basically a document that outlines whats covered and not covered under a health plan. This program will be available on January 1, 2020. Original Medicare generally covers most pre-existing conditions. Many Medicare Advantage plans, however, do include coverage for routine dental, vision and hearing care, including glasses and hearing aids. 1 Sturti / Getty Images Coverage Varies by Insurer Each health plan is different. Franchise Tax Your private health information is just that private. Procedures can cost from $700 to $2,000 per eye, depending on . <. If permitted, you may only be responsible for the negotiated fee. Inpatient hospital: $450 per admission copay for unlimited days, plus 35% of our allowance. Whats especially helpful is that every health plan has to use the same outline to show the costs and coverage for each of the plans they offer. Enter your ZIP code below to see plans with their premiums, copays, and participating doctors and pharmacies. Transparency Starting January 1, 2018, HIP State Basic and HIP State Plus will cover members age 21 to 64. Please use this access code on website: surgeryplus. Medicare Part B (medical insurance) helps cover the cost of medically necessary durable medical equipment if your doctor prescribes it for use in your home. To provide and maintain this valuable membership benefit, MetLife reimburses the association and/or the plan administrator for these costs. 0000011564 00000 n 0000024262 00000 n Its also possible to get an SBC in another language. L0920007743[exp0922][All States][DC,GU,MP,PR,VI] 2020 MSS, Florida office (headquarters) The documentation requirements outlined below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested. This may include surgery to remove cataracts or after an eye injury. startxref Gross Receipts Tax *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. About Us; Staff; Camps; Scuba. 0000009101 00000 n 10 frequently asked questions about Medicare plans, Deductibles for Medicare Part A and Part B. Personal Income Tax EXA!YA?fqLv1bd::M&a54g#A010p]p hb```b``Nf`c`Wcd@ AV(G 2?X%c6g+S@|dHA[&@VS&-,&W\\f9v| **s)S\Ol%5T7A(F A reminder that the SBC is only a summary. 00k` !" You can choose whether or not to use SurgeryPlus for your surgical procedures. Cancellation/Termination of Benefits You'll be more confident on the beach with an extensive selection of plus-size swimwear. trailer Hospice care, Medicare.gov, last accessed June 10, 2022. Voting & Elections These plans include all your Part A and Part B coverage and often provide extra coverage for services not included in Original Medicare. 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. "Original Medicare may cover 80% of a traditional cataract surgery. Inpatient (Precertification is required): $350 per admission. You are always free to select the dentist of your choice. 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. endobj Home. Medically necessary services diagnose and treat health problems. The sharing of health information between these companies is permitted by regulation. Medicare Advantage plans are provided by private companies with approval from Medicare. 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. If it contains a form, you can print it and fill it out. Complete and submit the form and well be in touch soon. This benefit is available to those enrolled in one of the CEBT EPO, PPO or HDHP medical plans. Negotiated fees are subject to change. Medicare pays 80% of the cost of traditional cataract surgery, which would be covered by Medicare Part B. This website provides an overview of your benefit options. Tax Center Outpatient facility care: 35% of our allowance . Jacksonville, FL 32256 Knowing which types of common medical costs are not covered will be helpful when planning for your out-of-pocket medical costs. This group plan is made available to through membership in the American Association of Business Networking (ABN). Corporations Yes. (Negotiated fees are subject to change.). Please contact MetLife or Member Benefits, your plan administrator at 1-800-282-8626 for costs and complete details. Heres a step-by-step look at what information is in an SBC: You can request a copy of an SBC anytime. 89 37 0000014887 00000 n Coverage will be considered under your out-of-network benefits. So you may be responsible for any difference in cost between the dentists fee and your plans benefit payment. The SurgeryPlus Difference We allow you to focus on practicing medicine and caring for patients. Metlife will not pay Dental Insurance benefits for charges incurred for: Alternate Benefits Locations Directory 0000004000 00000 n In addition, it comes with a concierge service (Care Advocate) and travel benefits. ii AF! 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. endstream endobj startxref Each company is a separate entity and is not responsible for another's financial or contractual obligations. Please contact Member Benefits your plan administrator at 1-800-282-8626 for more information. 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. Delaware Courts Durable medical equipment (DME) coverage, Medicare.gov, last accessed June 10, 2022. 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. All rights reserved. Medicare Advantage plans may offer coverage for vision, hearing, dental and wellness services. He or she hasnt agreed to accept negotiated fees. Procedure charge schedules are subject to change each plan year. Filing a health claim. Mon-Fri, 8:30am-5:00pm (CT). endstream Hearing & balance exams, Medicare.gov, last accessed June 10, 2022. 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. Reconstructive Procedures include surgery or other procedures which are related to a health condition. For example, if youre still working and covered by your employer or your spouses employer sponsored health coverage, you may be able to wait. 1026 0 obj 1. However, if you choose a non-participating dentist, your out-of-pocket costs may be higher. HV[kH~GTfJ4C-lKM#si+4swzZ\|P/_^jji>W(W^"SZE~?xerLgibT}gyQtjSFGil2ZZb6#NWM[]uT{:Gk)0 >IZn,:-/855fOneI4nUGqK9G{-hb!E|VXM)65}`OLX|Tb)k``K}L@6%y+ba}f[#e5pr>i:r. Looser styling flatters while cleverly camouflaging around your middle. Plan benefits and rates are effective for group plan year January 1, 2023 through December 31, 2024, and subject to change thereafter. Please fill out the contact form so the right person can be in touch quickly.
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