Dental, Vision and Hearing Select

This is a Limited Benefit Insurance Policy for Dental, Vision and Hearing Expenses.

The Importance of Dental | Vision | Hearing

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Help maintain quality of life
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Financial protection in unforeseen situations that are painful, inconvenient, and expensive
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Basic Medicare does not cover dental, vision or hearing expenses

PRODUCTS HIGHLIGHTS

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Individual ages 18 – 99
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Family rates (include up to 3 children)

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$0 or $100 deductible
(does not apply to Preventive Services)

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Glasses, Contacts and Hearing Aid benefits
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Guaranteed renewable for life*
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Choose your dentist (in-network or out-of-network)

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$1,000, $1,500, or $3,000 policy year maximum benefit
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Orthodontia benefit
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Guaranteed issue

* Subject to our right to change premiums.

Flexibility to choose . . .

Dental Only

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Dental and Vision

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Dental & Hearing
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Dental, Vision & Hearing
accident insurance in texas
Dental, Vision and Hearing Select from ManhattanLife was designed with you in mind. With the ability to choose specific benefits, you can customize a plan tailored to fit your needs.

26% of adults in the United States have untreated tooth decay.
46% of adults aged 30 years or older show signs of gum disease.

Plan
Benefits

Plan Benefits

Eligibility: Ages 18 – 99
Policy Year Maximum Benefit: $1,000, $1,500 or $3,000
Policy Year Deductible: $0 or $100 per person (does not apply to Preventative Services)

Dental Coverage

 In-Network Out-of-Network
Preventive Services
• Dental Exams; 2 per year
• Cleanings; 2 per year
• Bitewing X-Rays; 2 per year
• Fluoride treatment is for age 16 and under; 2 visits per year
100% of
contracted rate
80% of UCR
Basic Services
• Limited Oral Evaluation
• Diagnostic Consultation
• Emergency
• Emergency Palliative Treatment • Panoramic X-Ray
• Periapical X-Ray
• Periodontal Non-Surgical Service
• Basic Restorative Service
• Filling
• Basic Oral Surgery
• Periodontal Service
• Non-Surgical Extraction
65% of contracted
rate 1st yr.

80% thereafter
65% of UCR 1st yr.

80% thereafter
Major Services
• Major Restorative Service
• Inlay/Onlay/Crown
• Endodontic Service
• Periodontal Service
• Prosthodontic Service
• Implants
20% of contracted
rate 1st yr

50% thereafter
20% of UCR 1st yr

50% thereafter
All Other Medically Necessary Services
(services not listed above)
20% of contracted rate 1st yr.

50% thereafter
20% of UCR 1st yr

50% thereafter
Orthodontia
• Straightening of teeth (for all ages)
• Lifetime max $1,5002
Year 1 - N/A

Year 2+ - 50%
N/A

Vision Rider

 In-NetworkOut-of-Network
Vision Services
• Eye Exam
• Refraction
• Single Lenses
• Bifocal Lenses
• Trifocal Lenses
• Progressive Lenses
60% of UCR 1st yr.
70% of UCR 2nd yr.
80% of UCR thereafter
1 per year
• Eyeglass Frame
• Contact Lenses
$200 maximum per year
• Anti-Reflective Lenses$45; 1 per year
• Polycarbonate Lenses$40; 1 per year
• Contact Lens Fitting Fee$15; 1 per year

Hearing Rider

 In-NetworkOut-of-Network
Hearing Services
• Hearing Exam
• Hearing Aid and Necessary Repairs or Supplies
$750 maximum
(per ear, per year)

CAREINGTON NETWORK*

Clients can access the Careington Maximum Care PPO Dental Network. Use of network is
completely optional.

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Policyholders can benefit from choosing a dental provider from the Careington Dental Network
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Policyholders can also use the dentist of their choice, even if they are not part of the dental network
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Network discounts may help extend the policy year maximum with reduced charges.
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Careington can be contacted at (800) 290-0523.
Discounted fees to help your
dental benefits go further
Access to quality dentists all
around the country
100,000+
Dentists Nationwide

So while you can choose your own dentist, visiting a Careington dental network provider offers greater savings and discounts. Visit https://www1.careington.com/ to find a Careington dentist near you

* Subject to our right to change premiums.

Understanding How Your Benefits Work

Dental Coverage

In-Network
Peter goes to his Careington Network dentist for a regular check-up. Upon examination, the dentist realizes that Peter needs a filling. Luckily, Peter has a Dental Plan with ManhattanLife. He has met his $100 annual deductible.
Procedure:Provider Chargee In-Network CostManhattanLife PaysYou Pay
Dental Exam$150$35 100% Preventative day one;
$35.00
$0
Filling$275$99 65% Basic day one;
(of In-Network Cost = $64)
$35
($99 - $64
Total$425$134$99$35
Out-of-Network
Peter chose not to use the Careington Network and instead goes to an out-of-network dentist for a regular checkup. Upon examination, the dentist realizes that he needs a filing. Peter has a Dental plan with ManhattanLife. He has met his $100 annual deductible.
Procedure:Provider Chargee In-Network CostManhattanLife PaysYou Pay
Dental Exam$150$9680% Preventative day one;
(of Usual and Customary = $77)
$73
($150 - $77)
Filling$225$17565% Basic day one;
(of Usual and Customary = $114)
$111
($225 - $114)
Total$375$271$191$184
*subject to the Usual and Customary charges based in zip code 77092

Vision Rider

Earl goes to the Eye Doctor for an eye exam and gets glasses. He has had a Dental + Vision plan with ManhattanLife for over a year and has met his annual deductible.
Procedure:CostManhattanLife PaysYou Pay
Eye exam$6070% year two
$42
$0
Eyeglass Frame$250$200 maximum;
$200
$35
($99 - $64
Lenses$11570% year two
$81
$35
($99 - $64
Total$$425 $323$35
*subject to the Usual and Customary charges based in zip code 77092

Hearing Rider

After a 12 month waiting period Brian decides to get his hearing checked, as he’s noticed a progressive hearing decline. His ENT specialist recommends Brian get hearing aids to help relieve the hearing loss. Utilizing the hearing portion of the plan, his exam and devices would have been covered as follows:
Procedure:CostManhattanLife PaysYou Pay
Hearing Exam$90$750 maximum per ear, per year:
$90
$0
Hearing Aids$1,600$750 maximum per ear, per year:
$1,500 - $90 (Hearing Exam) = $1,410
$190
Total$1,690$1,500$190
*subject to the Usual and Customary charges based in zip code 77092
*For illustrative purposes only. Claims examples are subject to geographic region, out of network provider and usual & customary charges.

Dental, Vision & Hearing Select Monthly Rates*

Dental Coverage

$1,000 Maximum Benefit
$0 Deductible$100 Deductible
AgeIndividualIndividual + Spouse**Individual + Child(ren)FamilyAgeIndividualIndividual + Spouse**Individual + Child(ren)Family
3 - 17$28.29 3 - 17$25.98
18 - 39$30.49$60.9$72.91 $110.4718 - 39$27.12 $54.24$66.09$99.71
40 - 54$38.88 $77.75$107.16 $131.49 40 - 54$34.80 $69.60$96.98$118.97
55 - 64$41.43 $82.85$99.47 $121.0455 - 64$37.32 $74.64$90.19 $109.72
65 - 74$43.69 $87.37$86.16$101.52 65 - 74$39.46 $78.93$77.94$91.92
75 - 99$46.58 $93.17$88.58 $100.2475 - 99$41.87 $83.75$79.71 $90.24
$1,500 Maximum Benefit
$0 Deductible$100 Deductible
AgeIndividualIndividual + Spouse**Individual + Child(ren)FamilyAgeIndividualIndividual + Spouse**Individual + Child(ren)Family
3 - 17$30.103 - 17$27.78
18 - 39$32.41$64.82$77.56 $117.5018 - 39$28.92$57.84$70.59$106.45
40 - 54$41.48 $82.96$114.20$140.1540 - 54$37.24$74.48$103.74$127.26
55 - 64$44.32 $88.65$106.24$129.2855 - 64$37.32 $80.08$96.65$117.58
65 - 74$46.91 $93.82$92.45 $108.8765 - 74$42.49$84.98$83.87$98.87
75 - 99$50.21$100.42$95.42$$107.9475 - 99$45.28$90.56$86.14$97.50
$3,000 Maximum Benefit
$0 Deductible$100 Deductible
AgeIndividualIndividual + Spouse**Individual + Child(ren)FamilyAgeIndividualIndividual + Spouse**Individual + Child(ren)Family
3 - 17$35.263 - 17$32.30
18 - 39$36.45$72.89$89.33$134.5918 - 39$32.65$65.29$81.09$121.81
40 - 54$46.97$93.95$131.21$160.9440 - 54$42.34$84.68$119.08$146.04
55 - 64$50.49$100.98$122.13$148.5755 - 64$45.78$91.56$111.12$135.16
65 - 74$53.78$107.56$106.18$125.1965 - 74$48.90$97.81$96.61$113.95
75 - 99$57.86$115.73$110.05$124.5475 - 99$52.42$104.84$99.74$112.91

* In CA, Spouse or Registered Domestic Partner; In DC, Spouse, Domestic Partner, or Civil Union Partner; In OR, Domestic Partner.

* Subject to our right to change premiums.

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