2023-2024 Benefits Guide 3.28.2024

Pick the plan that best suits your needs

Value Plan

Network Access Plan (NAP)

In-network and out-of-network benefits are paid at the same coinsurance percentages. Both plans allow you to retain the freedom of choice to see any dentist, in-network or out of network.

Description

Preventive services covered at 100%. Coinsurance for other services is higher than the Network Access Plan (increased coverage).

Preventive services covered at 100%. Coinsurance for other services is lower than the Value Plan (decreased coverage).

Coinsurance

In-Network

Member benefits are based on discounted (negotiated) rates.

Out-of-Network Member pays the difference over network negotiated rates.

Member costs are based on usual and customary (UCR) rates.

For additional information regarding the various services and how often you may receive services, please refer to the Summary of Benefits located at the end of this booklet.

Employee Bi-Weekly Cost

Premiums are the same for either plan. Employee only dental coverage is offered at no cost to employees. If dependents were to be added, then employees will be responsible for the difference of their premium amounts. Refer to the table on the left to view monthly and bi-weekly costs.

Employee Monthly Cost

Dental Rates

Employee Only

$0.00

$0.00

Employee + Spouse Employee + Child(ren) Employee + Family

$30.37 $49.60 $87.58

$15.19 $24.80 $43.79

Guardian’s Dental Maximum Rollover With Maximum Rollover, Guardian will roll over a portion of the unused annual dental maximum into a personal Maximum Rollover Account (MRA), which can be used in future years if the plan’s annual maximum is reached. As an added advantage, additional money is rolled over if in- network dentists are used exclusively during the benefit year. To qualify, a member must have a paid claim (not just a visit) and must not have exceeded the paid claims threshold during the benefit year. Each member's MRA may not exceed the MRA limit. The employee and each enrolled dependent maintain separate MRAs based on their own claim activity. You may view your annual MRA statements online at wvw.GuardianAnytime.com How Maximum Rollover Works If you use $700.00 or less of the $1,500.00 annual maximum and submit at least one claim, then you will be eligible to rollover up to $350.00 of the annual maximum not used. You can accumulate up to $1250 over an extended period of time. ANNUAL MAXIMUM: $1,500.00 THRESHOLD $700.00 MAX ROLLOVER AMOUNT $350.00 IN-NETWORK ONLY ROLLOVER AMOUNT $500.00 MAX ROLLOVER ACCOUNT LIMIT $1,250.00

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