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Group Dental Plan

With The Guardian's PPO Program, you have options each time you need dental care. If you use an in-network dentist your out-of-pocket expenses will be lower. The Guardian has negotiated a fee schedule with in-network providers. You pay a percentage of an already discounted fee, which means lower costs.

Or, you can visit any out-of-network licensed dentist. The Guardian will pay a percentage of allowable (usual and customary) charges.

Eligibility
Physicians Only:
Association/Society members may apply as individuals to the Physician's dental program only during special annual open enrollment periods.

In order to apply you must be:

• Actively engaged in the duties of your profession at least 30 hours per week

Eligible dependents:

• Spouse

• Unmarried, dependent children are under age 23 (age 25 if a full-time student)

Physicians and Employees:
Groups of physicians and employees may apply for dental coverage at any time. However, if individuals in a group do not enroll when first eligible (within the first 60 days of employment), they are subject to a late entrant penalty. If enrolling after the first 60 days of employment, benefits are payable immediately for Preventive Services, for Basic Services after 6 months of coverage, and for Major Services after 12 months.

Employees of members may apply if:

• Actively working for an Association/Society member at least 30 hours per week

Maximum Rollover Benefit
This benefit allows an individual to rollover a portion of his or her unused annual maximum benefit each year as long as paid claims do not exceed a preset paid claims threshold. The rollover amount is deposited into a member's MRA (maximum rollover account) for use with future dental expenses. The MRA may be used when a member exceeds the maximum annual plan benefit in any future year.

The maximum per person calendar year non-PPO benefit is $1,500 per person per calendar year ($2,000 under the PPO). As long as a covered individual does not exceed the annual $700 threshold in paid claims, he or she will have $350 accrued for future use in an MRA. If a member utilized only the services of a PPO provider during a year, then $500 will be added to the MRA. The maximum account balance is $1,250 per individual. When a covered individual exceeds the maximum annual plan benefit in any future year, additional benefits may be paid from the MRA.

Participation Requirements
The following participation requirements must be met:

• Groups require 75% participation
• A DE3 verifying participation information is required
• An Equifax report paid by the insurance company may also be necessary County Medical Association/Society Sponsored PPO Group Dental Program

County Medical Association/Society Sponsored PPO Group Dental Program

 

	In-Network	Out-of-Network
Maximum Benefit	$2,000 per person, per calendar year	$1,500 per person, per calendar year
Deductible, Calendar Year	$50 per person, $100 per family	$50 per person, $100 per family
Preventive Services Oral exams, X-rays, teeth cleaning, flouride treatments, topical sealants	100% of negotiated fee schedule (deductible waived)	80% of allowable charges (deductible waived)
Basic Services Lab tests, amalgam, silicate or acrylic fillings, root canal, oral surgery, anethesia, stainless steel & acrylic crowns	80% of negotiated fee schedule	70% of allowable charges
Major Services Gold & porcelain fillings & crowns, prosthetics — subject to waiting period of 12 months	50% of negotiated fee schedule	40% of allowable charges
Endodontics/Periodontics	80% of negotiated fee schedule	70% of allowable charges
Orthodontia Subject to waiting period of 12 months	50% of negotiated fee schedule — $500 per calendar year maximum	40% of allowable charges — $500 per calendar year maximum

 

Maximum Rollover Examples:

Maximum Annual Benefit per Person	Paid Claims Threshold Amount	Maximum Rollover Amount	In-Network Only Services Maximum Rollover Amount	Maximum Rollover Account (MRA) Limit
$1,500 per person per cal yr.	$700	$350	$500	$1,250

 

Here is an example of how this new benefit can work for an individual:

Year	Annual Paid Claims for an Individual	PPO Providers Only?	Paid Claims Greater than $700	Result	Balance in MRA
1	$400	No	No	$350 credited to MRA	$350
2	$900	No	Yes	$0 credited to MRA	$350
3	$600	Yes	No	3 $500 credited to MRA	$850
4	"$2,100*"	No	Yes	$0 credited to MRA; $600 withdrawn from MRA	$250
*Assumes all services provided by out of network dentists

Termination
Your coverage will terminate:

• If you fail to pay your quarterly premium
• If you cease to be a member of the Association/Society

Dependent coverage will terminate when:

• A person no longer qualifies as a dependent
• The period for which coverage has been paid ends
• Your coverage as an Association/Society member ends

Employee coverage will terminate:

• If you or your employer fails to pay your quarterly premium
• If you cease to be an employee of an Association/Society member
• If your employer ceases to be an Association/Society member
• When you retire

Dental Exclusions
The plan does not pay for:

• Oral hygiene, plaque control or diet instruction; or precision attachments
• Treatment which does not meet accepted standards of dental practice or treatment which is experimental in nature
• Orthodontic treatment, unless the plan provides specific benefits
• Any appliance or prosthetic device used to:
  1. change vertical dimension;
  2. restore or maintain occlusion, except to the extent that this plan covers orthodontic treatment;
  3. splint or stabilize teeth for periodontic reasons;
  4. replace tooth structure lost as a result of abrasion or attrition; and
  5. treat disturbances of the temporomanibular joint
     
     
• Replacing an appliance or prosthetic device with a like appliance or device, unless;
  1. it is at least 5 years old and can't be made usable; or
  2. it is damaged while in the covered person's mouth in an injury suffered while he is insured, an can't be fixed
     
     
• Replacing a lost, stolen or missing appliance or prosthetic device or making a space appliance or device
• Treatment needed due to:
• an on-the-job or job-related injury; or
• a condition for which benefits are payable by Workers' Compensation or similiar laws.

How To Apply
Please complete each question on the application, located in the forms section, and return to us. Send No Money Now. You will be billed for your payment upon approval of your application by The Guardian.

Questions?
A Client Service Representative is available to answer your questions. Please call Marsh at (800) 842-3761.

© 2007 Seabury & Smith Insurance Program Management 11/07.

The information on this Web site is intended to outline the principal features of the group insurance program. All statements are subject to the terms of the contract between the Planholder and The Guardian Life Insurance Company of America. Additional details on covered expenses and exclusions are to be found in the certificate booklet given to each insured individual.

Administered by:

Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer, and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

The premium quoted includes compensation of 15% from The Guardian Life Insurance Company received by Marsh for providing services that may include enrollments, ongoing servicing, billing and communications. All marketing expenses associated with this program are paid by Marsh.

Underwritten by:
The Guardian Life Insurance Company of America
7 Hanover Square, New York, NY 10004

Important Information about Guardian's DentalGuard Indemnity and DentalGuard Preferred PPO Plans: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. Waiting periods may also apply for some services. The plan does not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimental treatments, any treatment to the extent benefits are payable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment. The plan limits benefits for diagnostic consultations and for preventive, restorative, endodontic, periodontic and prosthodontic services. The services, exclusions, and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. GP-1-DG2000, et al.

Seabury & Smith Insurance Program Management
777 South Figueroa Street, Los Angeles, CA 90017
CMACounty.Insurance@marsh.com
CA License #0633005
(800) 842-3761

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Mailing Address:

Marsh U.S. Consumer PO Box 9279 Des Moines, IA 50306-9279

Street Address for express shipment:

Marsh U.S. Consumer 12421 Meredith Drive Urbandale, IA 50323

Call Center:

Phone:  1-800-988-6420  (7:00 a.m. to 8:00 p.m. Central, M-F)

Email:

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