Group Dental Insurance

Choose from two levels of coverage underwritten by Metropolitan Life Insurance Company

mother and daughter brushing teeth

COVERAGE FOR DENTAL CARE THAT'S EASY TO SMILE ABOUT

Maintaining a healthy smile can play an important role in your overall health, but regular trips to the dentist can easily become a financial burden. The TXCPA Group Dental Insurance plan can help you manage your dental expenses.

Our policy helps cover the cost of preventive, basic and major dental services, including exams, cleanings, fillings, and extractions, as well as crowns, bridges, and dentures.

Features of this Coverage:

  • Choose from two plans, depending on your needs and budget
  • Benefits payable for preventive care without a waiting period
  • Coverage available for spouse/domestic partner and dependent children
  • No deductible for preventive care
  • Access to thousands of dentists and specialists throughout the country

As a member of TXCPA, you and your spouse/domestic partner* and eligible dependents may enroll for coverage. Eligible dependents include children age 26 or younger. You and your eligible spouse and dependents must reside in the United States.

Not available to AK, ID, LA, ME, MD, MT, NH, OR, SD and WA. Residents of the state of California who are 65 years of age or older are not eligible for this coverage.

* Domestic partner includes your registered domestic partner if you and your domestic partner are registered as domestic partners, civil union partners, or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non-registered domestic partner in whom you have an insurable interest. By enrolling such domestic partner for coverage, you are attesting to your insurable interest.

High Plan

Annual Maximums: You and your covered dependents are entitled to receive up to $2,000 each in dental benefits in any calendar year after the cash deductible is satisfied.

Deductibles: For Type B (basic) and Type C (major) services, an annual deductible of $50 is required for individual coverage. For family coverage, the annual deductible is $150. For Type A (preventive) services, the deductible is waived.

Coverage: You and your eligible dependents are covered for dental services according to the following guidelines:

  • Type A (preventive): 100%
  • Type B (basic): 80%
  • Type C (major): 40%

The reimbursement schedule for dental services is the same, regardless of whether you choose an in-network or out-of-network dentist. However, your out-of-pocket costs may be higher with an out-of-network dentist. Out-of-network dentists have not agreed to accept negotiated fees,* which are typically 30-45% less than the average fees** charged in a dentist’s community for the same or similar services.

Low Plan

Annual Maximums: You and your covered spouse and dependents are entitled to receive up to $1,000 each in dental benefits during any calendar year after the cash deductible is satisfied.

Deductibles: For Type B (basic) and Type C (major) services, an annual deductible of $75 is required for individual coverage. For family coverage, the annual deductible is $225. For Type A (preventive) services, the deductible is waived.

Coverage: You and your eligible dependents are covered for dental services according to the following guidelines:

  • Type A (preventive): 80%
  • Type B (basic): 60%
  • Type C (major): 50%
     

The above schedule for dental services is the same, regardless of whether you choose an in-network or out-of-network dentist. However, your out-of-pocket costs may be higher with an out-of-network dentist. Out-of-network dentists have not agreed to accept negotiated fees,* which are typically 30-45% less than the average fees** charged in a dentist’s community for the same or similar services.

* Negotiated fees refer to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any co-payments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

** Based on internal analysis by MetLife. Savings from enrolling in a dental plan will depend on various factors, including how often participants visit the dentist and the costs for services rendered.

Both the High Plan and the Low Plan cover preventive, basic, and major dental services. Specific services covered under each plan are outlined below. This website presents the majority of services within each category, but is not a complete description of the plan.

Preventive Services – Type A

  • Prophylaxis (regular cleanings): Two per calendar year, separated by six months
  • Oral examinations: Two exams per calendar year, separated by six months
  • Examinations – problem focused: Combined with examinations limit
  • Topical fluoride applications: One fluoride treatment per 12 months for dependent children up to age 14
  • Periodontics: Total number of periodontal maintenance treatments and prophylaxis (regular cleanings) cannot exceed two treatments in a calendar year, separated by six months
  • Full mouth x-rays: Once every 60 months
  • Bitewing x-rays: One set per 12 months for adults; two sets per calendar year for children under age 19, separated by six months
  • Space maintainers: One per lifetime for a child under age 14
     

Basic Services – Type B

  • Fillings: One replacement per surface in 24 months
  • Resin composite fillings: Excludes coverage for composite fillings on molars
  • Simple extractions
  • Oral surgery
  • General anesthesia: When dentally necessary in connection with oral surgery, extractions, or other covered dental services
  • Sealants: One application every three years for each non-restored, non-decayed first and second molar of a dependent child under age 16
     

Major Services – Type C

  • Endodontics: Root canal treatment limited to once per tooth per 24 months
  • Periodontics: Periodontal scaling and root planing once per quadrant, every 24 months
  • Periodontal surgery: Once per quadrant, every 36 months
  • Implant services/prosthetics: One per tooth every seven years
  • Implant repairs: One per tooth in 12 months
  • Bridges and dentures: Initial placement to replace one or more natural teeth, which are lost while covered by the plan
  • Bridges and dentures – replacements: Once every seven calendar years; replacement of an existing temporary full denture if the temporary denture cannot be repaired and the permanent denture is installed within 12 months after the temporary denture was installed
  • Crown, denture, and bridge repair/recommendations: Once every 24 months
  • Crowns, inlays, and onlays: Replacement once per tooth every five calendar years
  • Consultations: Two in 12 months
  • Occlusal adjustments: One in 12 months
     

Is Orthodontia a Covered Service?
Your children, up to age 19, are covered for orthodontic diagnostics and treatment under the High Plan at a 50% reimbursement rate. The lifetime maximum is $1,000. Orthodontia is not covered under the Low Plan.

Your dental coverage will become effective following receipt of your enrollment form and first premium payment.

Your dental coverage will remain in effect unless you fail to pay the appropriate premium when due, or the group policy is discontinued. Coverage for dependents will end at age 26.

For services provided by an in-network dentist, benefits will be paid directly to the dentist. For services provided by an out-of-network dentist, you can request that benefits be paid either directly to your dentist or directly to you. Claims are payable immediately from the start date of your coverage.

No benefits will be paid for the following:

  • Services which are not dentally necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature
  • Services for which you would not be required to pay in the absence of dental insurance
  • Services or supplies received by you or your dependents before the dental insurance starts for that person
  • Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate of Insurance)
  • Services which are neither performed nor prescribed by a dentist, except for those services of a licensed dental hygienist, which are supervised and billed by a dentist and which are for:

o   Scaling and polishing of teeth
o   Fluoride treatments

  • Services or appliances which restore or alter occlusion or vertical dimension
  • Restoration of tooth structure damaged by attrition, abrasion, or erosion
  • Restorations or appliances used for the purpose of periodontal splinting
  • Counseling or instruction about oral hygiene, plaque control, nutrition, and tobacco.
  • Personal supplies or devices including, but not limited to: water picks, toothbrushes, or dental floss
  • Decoration, personalization, or inscription of any tooth, device, appliance, crown or other dental work
  • Missed appointments
  • Services:

o   Covered under any workers’ compensation or occupational disease law;
o   Covered under any association liability law;
o   For which the association of the person receiving such services is not required to pay; or
o   Received at a facility maintained by the policyholder, labor union, mutual benefit association,  or VA hospital

  • Services covered under other coverage provided by the policyholder
  • Temporary or provisional restorations
  • Temporary or provisional appliances
  • Prescription drugs
  • Services for which the submitted documentation indicates a poor prognosis
  • Services, to the extent such services, or benefits for such services, are available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. 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.
  • The following when charged by the dentist on a separate basis:

o   Claim form completion;
o   Infection control such as gloves, masks, and sterilization of supplies; or
o   Local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide

  • Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food
  • Caries susceptibility tests
  • Initial installation of a fixed and permanent denture to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
  • Other fixed denture prosthetic services not described elsewhere in the certificate
  • Precision attachments, except when the precision attachment is related to implant prosthetics
  • Adjustment of a denture made within 6 months after installation by the same dentist who installed it
  • Duplicate prosthetic devices or appliances
  • Replacement of a lost or stolen appliance, cast restoration, or denture
  • Intra- and extra-oral photographic images
  • Fixed and removable appliances for correction of harmful habits
  • Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards
  • Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents of Minnesota
  • Orthodontia services in the Low Plan
  • Repair or replacement of an orthodontic appliance
  • Initial installation of a full or removable denture to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
  • Addition of teeth to a partial removable denture to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
  • Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
     

Alternate Benefit

If we determine that a service less costly than the Covered Service the Dentist performed could have been performed to treat a dental condition, we will pay benefits based upon the less costly service if such service:

  • would produce a professionally acceptable result under generally accepted dental standards
  • also would qualify as a Covered Service

Coverage is provided under a group insurance policy (Policy Form GPNP99-TRUST (7/10)) issued by Metropolitan Life Insurance Company. Subject to the terms of the group policy, rates are effective for one year from your plan’s effective date. Once coverage is issued, the terms of the group policy permit Metropolitan Life Insurance Company to change rates during the year in certain circumstances.

Coverage terminates when you cease to be a member of TXCPA, when your dental contributions cease, upon termination of the group’s participation in the Trust, or insurance ends for your class.

Coverage for dependents ends if your insurance ends, on the date you die, the group policy ends, participation in the Trust ends, the date dependents’ insurance ends under the group policy, insurance for your dependents ends for your class, the person ceases to be a dependent or premium is not paid for the dependent when due.

There is a 31-day limit for the following services that are in progress: Completion of a prosthetic device, crown, or root canal therapy after individual termination of coverage.

For rate information and to receive an enrollment form, please call the plan administrator at 1-800-845-8941. Online enrollment for this plan will resume in February 2024.


This website explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this website and the group policy issued to the Trustees of the TXCPA Insurance Trust), the terms of the policy apply.

All benefits are subject to the terms and conditions of the policy. Policies underwritten by Metropolitan Life Insurance Company detail exclusions, limitations, and terms under which the policies may be continued in full or discontinued.

Complete details about this coverage can be found in the Certificate of Insurance issued to each insured individual. In the event of any conflict between this plan summary and the Certificate of Insurance, the Certificate of Insurance controls. Insurance coverage and availability may vary by state.

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. Please contact your plan administrator at 1-800-845-8941 for costs and complete details.

L0124037328[exp0126][All States][DC,GU,MP,PR,VI] © 2024 MetLife Services and Solutions, LLC

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For information about rates and to request an enrollment form, please call:

1-800-845-8941

(online enrollment will resume February 2024)

Not available to residents of AK, ID, LA, ME, MD, MT, NH, OR, SD, and WA.

 

Sponsored by:
Texas Society of Certified Public Accountants (TXCPA)

 

Underwritten by:
Metropolitan Life Insurance Company
200 Park Avenue
New York, NY 10166
Policy Form GPNP99-TRUST

 

 

Administered by:
Forrest T. Jones & Company*
P.O. Box 418131
Kansas City, MO 64141-8131

*For Arizona residents, the administrator is Forrest T. Jones Consulting Company