Which MetLife Option is best for me?

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The MetLife HMO and MetLife PPO plans feature two different summary of benefits forms. These plans are very different (as you can see in this flier comparing the two), making it all the more important to understand what is exactly being offered in your summary of benefits. 

HMO Plan 

The MetLife HMO plan is the more transparent of the two plans. The summary of benefits explicitly states the exact price of individual dental services, materials, and office visits.  

These prices are the same at all in-network dentists, but with an HMO plan, you will have to choose one dentist and stick with them (unless there are extenuating circumstances).  

Since every service, test, and procedure is mapped out, navigating your MetLife HMO summary of benefits can be overwhelming. We recommend you use the PDF search function by holding “Ctrl” and pressing “F” on your keyboard. From there, you should be able to type most services in and see the copay for each procedure. 

It’s also important to know that these are stacking charges, meaning you will owe the copay listed for each procedure that you undergo at the dentist. We’re specifying this because, under the HMO plan, every office visit costs $5 to begin with and several procedures require multiple visits. Some procedures, like restorations, also involve a wide array of treatment steps, each having their own copay.  

This isn’t to say the HMO plan is not right for anyone or that it is unreasonable. We simply recommend you look closely at the individual listings and suggest that you talk with your dentist about the services you’re receiving to make sure you know how much you’ll be paying. 

It’s also important to specify that the procedures listed are the procedures that your dentist and MetLife agreed to offer. Meaning there might be restrictions when it comes to things like the crowns, alternatives to braces, and dentures.  

Again, talk with your dentist or contact our team of benefit specialists so we can help you understand your options. Our phone number is 888-315-8027 and our email address is support@sdpeba.org 

PPO Plan 

Where the HMO plan is more transparent, the PPO plan is a lot simpler. Each type of care is split into four categories, Type A, B, C, and Orthodontia. 

Each of these categories represents a type of care, as outlined in the charts below: 

Category of Care 

In-Network Coinsurance 

Out-of-Network Coinsurance  

Type A - Preventative  

100% 

100% 

Type B - Basic Restorative 

90% 

80% 

Type C - Major Restorative 

60% 

50% 

Type D - Orthodontia 

50% 

50% 

In this case, coinsurance is the percent of the procedure your insurance pays—meaning preventative care is completely covered. 

Examples of Each Care Category 

Type A  

Preventative Care 

Type B 

Basic Restoration 

Type C 

Major Restoration 

Type D 

Orthodontia 

Oral Exams 

Cleanings 

Full-Mouth X-Rays 

Sealants 

Root Canals 

Fillings 

Crowns 

Dentures 

Bridges 

Braces 

Retainers 

Any other related charges 

These are just examples of what each category offers, talk to your dentist or check your summary of benefits if a procedure you need is not listed.  

The PPO plan also offers partial coverage for alternate benefits, meaning if there’s an option that better suits you, you can still receive coverage.   

That might sound a little confusing, but really it just means you pay the cost for the substitution, but still receive coverage as if you were getting the non-alternative option. For example, if you need braces but opt instead for Invisalign, so long as MetLife acknowledges that this is an alternative to braces, you can still receive coverage. The coverage amount would be equal to the coinsurance cost of the cheaper option plus the difference in price for the alternative.  

Say braces cost $1,000. With the PPO plan, you’d pay $500 since you have a 50% coinsurance. If your dentist also offered Invisalign as an alternative for $1,250, you could get that instead, but you would end up paying $500 (the cost braces would have been) plus the $250 price difference for the two options. Meaning, you pay $750 for Invisalign 

This alternate benefit option applies to things like crowns, bridges, and dentures as well. Have a conversation about cost with your dentist whenever you want to make use of the “alternate benefits” option, so you’re never blindsided by costs.  

 

Need more information about your dental options? Click here. 

We’re dedicated to improving our resources to help you. If there’s anything in this article that needs further clarification or anything you have questions about then check out one of our support options. 

This is a link to our support page, where you can ask us questions directly. 

Our phone number is 888-315-8027 and our email address is support@sdpeba.org

 

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