If you request a plan design change, you will receive new Enrollment Kit for distribution to your employees.

Additional Enrollment Kits may be ordered through Client Broker Services Department at 1-800-ASK-4-MET (1-800-275-4638).

Any additions, terminations, or changes made after your bill print date will be reflected on your next invoice; therefore, please pay premium as billed.

For eligibility changes, please fax a MetLife Change Request Form to 1-888-505-7446.

Payments

Payments should be made to MetLife and should be submitted to the address on your bill.

Questions About Your Billing Statement

Please contact MetLife at 1-800-ASK-4-MET (1-800-275-4638) if you have questions about an item or any aspect of our billing process.

The Enrollment Kit contains explanations on what the DHMO plan covers and how to access benefits. It is only a summary. The Contract governs all rights and benefits. Your employee should review the summary of information and then complete the Enrollment Form.

• When a newly eligible employee is electing the DHMO plan; or
• When an existing employee is electing the plan for the first time during open enrollment.

Choosing A Dental Office

The DHMO plan requires employees to select a dentist when they enroll. This is requested on the Enrollment Form. When enrolling, the employee selects their first and second choice of a dental office. The SafeGuard Directory of Participating Dentists is available by calling SafeGuard Member Services at 1-800-880-1800.

If family members are also being enrolled, each dependent must be included on the Enrollment Form and must also select a dental office. Each covered dependent may elect a different dental office than the employee.

Checking Enrollment Forms

Incomplete or illegible information on the Enrollment Form may delay coverage for your employees. Please ensure that all required fields are completely filled in and clear. On the upper section of the Enrollment Form, please fill in your Group Name, Group Number and the effective date of coverage. All requested information is necessary in order to promptly and accurately enroll your employee.

Submit completed Enrollment Forms to:

Small Market Administration
P.O. Box 14593
Lexington, KY 40512-4593

Fax: 1-888-505-7446

DHMO Identification Cards

After MetLife receives the completed Enrollment Form, a letter which includes the employee's selected dentist facility information and ID card will be issued and sent to the subscriber's home address.

DHMO ID Card (Temporary)

A convenient way to provide the insured with a temporary DHMO ID card (while waiting to receive their permanent ID card), is to give this card to the insured before he/she goes to the dentist.  The permanent customized DHMO ID cards are shipped to the insured's homes shortly after implementing the coverage.

Please note: Identification cards are not required to obtain services. After the member's enrollment is effective, the member need only contact the selected SafeGuard dentist and make an appointment.

Please have the employee call 1-800-880-1800.

For Reporting All Other Changes and Terminations

MetLife must be notified of changes in employee status in one of the following ways:

• By sending a Change Request Form
• By making changes on your monthly billing statement and sending these changes with your remittance
• By indicating the change on MetLink, if you have access

Change Request Form:

Change Request Form

Please ensure the Group Name, Group Number and the effective date of change is completed on the change form.

Submit completed Change forms to:

Small Market Administration
P.O. Box 14593
Lexington, KY 40512-4593

Fax: 1-888-505-7446

Examples of Changes in Employee Status

Examples of changes that require notification include:

• Employee changes name
  
• Employee changes address
  
• Employee adds new dependent(s) to existing coverage
  
• Employee terminates dependent(s)
  
• Employee terminates coverage
  
• Employee reinstates COBRA coverage

Examples Of Plan Changes

Examples of policy modifications include changes in:

• Affiliates
• Class
• Employer contribution percentage
• Change of policy situs state
• Waiting period
• Benefit level

To terminate your policy, please follow these steps:

• Notify MetLife in writing. Notification should be sent to MetLife at least 60 days before your specified termination date. The policy will end on the later of the date stated in the notice; or the date MetLife receives the notice.
• Pay all unpaid premiums for the time your policy was in force. If MetLife receives a notice of termination request, all outstanding premiums must be paid in full before your request can be processed.

Please submit all request for termination to:
Fax 1-888-505-7446
Small Market Administration
PO Box 14593
Lexington, KY 40512-4593

Events Resulting in Termination

Your SafeGuard DHMO Plan terminates when:

• MetLife does not receive premium within the policy Grace Period.
• MetLife notifies you of failure to meet participation requirements.
• MetLife exercises its right not to renew the policy.
• You give MetLife written notice. You must pay all unpaid premium due for the period of time during which this policy was in force. MetLife recommends notification at least 31 days in advance of the termination date.

Your MetLife PPO Policy and SafeGuard DHMO Contract includes complete information on termination. Please review them carefully.

DHMO COBRA Form

COBRA Continuation Coverage

The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) is a federal law that requires employers with 20 or more employees for at least 50% of the business days of the prior calendar year to provide continuation of group dental coverage for employees, retirees and their dependents who are no longer eligible for coverage in the employer's insurance plan due to certain "qualifying events".

You should consult your legal counsel for specific questions or clarification about your COBRA obligations and responsibilities.

Notifying DHMO Participants of COBRA

When you are notified of a qualifying event, provide a Second Notice of COBRA Form and a DMHO COBRA Form within 14 days of notification. Complete the employer information and give the forms to the DHMO employee or dependents.

Send the COBRA Election Form along with a Change Request Form indicating the effective date of the COBRA coverage, the qualifying event and the forecast termination date to:

Small Market Administration
P.O. Box 14593
Lexington, KY 40512-4593

Fax: 1-888-505-7446

It is best to give the DHMO employee or dependents an Election Form for Continuation Coverage as soon as possible. The qualified beneficiary has 60 days from the date of that notice or from the date of the qualifying event, whichever is later, to elect COBRA continuation coverage. Then the qualified beneficiary has 45 days after electing coverage to pay the initial premium. To ensure the accuracy of your premium statement, you must notify MetLife immediately of termination of coverage.

You may find additional information regarding COBRA on the U.S. Department of Labor's website at: http://www.dol.gov/dol/topic/health-plans/cobra.htm.

Call Customer Service at 1-800-ASK 4-MET (1-800-275-4638) if you have any questions regarding the termination of COBRA benefits.

SafeGuard depends on the employer or the COBRA administrator to notify us of the terminations. We do not automatically terminate COBRA members when they have reached their limit.

Third Party Administrators and COBRA

Some Employers contract with a Third Party Administrator to assist them with billing and premium collection of their COBRA participants. If a Third Party Administrator is involved, there are some important facts we need to make you aware of:

• Your COBRA participants will be listed in a separate Division or Class on your monthly billing statement from MetLife.
• The total monthly premium due will include these COBRA participants.
• The premium remitted each month for active employees and COBRA participants must be received, in total, by the due date in order to avoid risk of termination for non-payment.
• MetLife does not participate in agreements with Third Party Administrators for COBRA billing and premium collection. That relationship exists strictly between the Employer and the Third Party.

Texas State Continuation of Dental Coverage is provided by state laws that require employers to provide continuation of group coverage for employees, retirees and their dependents who are no longer eligible for coverage in the employer's insurance plan due to certain "qualifying events".

This only applies in the state of Texas.

This section is intended to be used as a guide to help you administer State Continuation Coverage with respect to dental benefits only. It is suggested that you consult your legal counsel for specific questions or clarification about your specific state laws, obligations and responsibilities.

Notifying Insured of Their State Continuation of Coverage Rights

If the employee or dependent has a qualifying event, the employee or dependent should submit a written request to:

Small Market Administration
P.O. Box 14593
Lexington, KY 40512-4593

Fax: 1-888-505-7446

The employee or dependents should submit the written request as soon as possible. Please check the applicable state law for any notice requirements.

Continuation of group health coverages (dental) must be offered to every eligible employee and dependent whose coverage is terminated due to a qualifying event specified under the applicable state law.

Qualifying Events for State Continuation

The qualifying events vary from state to state. Review the State Continuation of Dental Coverage form for a list of qualifying events.

Length of Eligibility

Under each state law, certain qualifying events determine the length of eligibility of a participant.

When State Continuation Coverage Ends

State Continuation of Coverage may terminate earlier if applicable state law provides.

Call 1-800-ASK-4-MET (1-800-275-4638) if you have any questions.

DHMO COBRA Form

CAL-COBRA is a California law that provides continuation of group health coverage when an employer has 19 or fewer employees if the employer is no subject to Federal COBRA. You must notify MetLife within 30 days of your plan becoming subject to Federal COBRA, i.e. when you have 20 or more employees for the required period.

When a subscriber notifies you of a qualifying event, e.g. divorce, or when you become aware of a qualifying event, e.g. separation from employment, provide a Second Notice of COBRA Form and a DMHO COBRA Election Form within 14 days of notification. Complete the employer information and give the forms to the employee or dependents.

You must notify MetLife within 30 days of your actual knowledge of the qualifying event, e.g. by receipt of notice from the qualified beneficiary or your knowledge such as termination of employment. Send the DMHO COBRA Election Form along with a Change Request Form indicating the effective date of the COBRA coverage, the qualifying event and the forecast termination date to:

Small Market Administration
P.O. Box 14593
Lexington, KY 40512-4593

Fax: 1-888-505-7446

It is best to give the employee or dependents an Election Form for Continuation Coverage as soon as possible. The qualified beneficiary has 60 days from the date of that notice or from the date of the qualifying event, whichever is later, to elect CAL-COBRA continuation coverage. Then the qualified beneficiary has another 45 days after election of CAL-COBRA to make the initial premium payment.

Continuation of group health coverages (dental) must be offered to every employee and dependent whose coverage is terminated due to a qualifying event under CAL-COBRA.

Qualifying Events For CAL-COBRA

A qualifying event is any of the following events if they cause an employee's or dependent's coverage to terminate.

For Employee:

• Termination of employment (for any reason other than gross misconduct) or reduction in hours.

For Spouse:

• Death of the employee.
• Termination of employee's employment (for any reason other than gross misconduct) or reduction in hours.
• Divorce or legal separation from the employee.
• Employee becomes entitled to Medicare.

For Dependent Child:

• The death of the covered parent.
• Termination of employee's employment (for any reason other than gross misconduct) or reduction in hours.
• Divorce or legal separation.
• A parent becomes entitled to Medicare.
• The dependent ceases to be a dependent child under the plan.

Please note:

A child born to, or placed for adoption with, the employee during CAL-COBRA continuation coverage is entitled to continuation of coverage.

To ensure the accuracy of your premium statement, you must notify MetLife immediately of termination of coverage.

Exceptions For CAL-COBRA

The right to continue does not apply:

• to a person who does not reside in California;
• to a person who is covered by, or eligible to be covered by, Medicare;
• to a person who is covered, or who becomes covered, by another group benefit plan that does not have an exclusion or limitation for preexisting conditions that applies to the person;
• to a person who is covered, becomes covered, or could become covered by Federal COBRA (Section 4980B of the United States Internal Revenue Code);
• to a person who is covered, becomes covered, or could become covered, under a plan governed by Chapter 6A of the Public Health Service Act, 42 U.S.C. Section 300bb-1 et seq., relating to Requirements for Certain Group Health Plans for Certain State and Local Employees;
• to a person who fails to meet any one or more of the time limits set forth above for notice and election of coverage;
• to a person who fails to submit the correct premium when or before it is due;
• if at the time coverage under the plan ends the employer has 20 or more employees; or
• if the employer fails to notify MetLife of an employee termination or reduction in hours within 31 days.

Length of eligibility for CAL-COBRA

Under CAL-COBRA regulation, certain qualifying events determine the length of eligibility of a CAL-COBRA participant. These events for CAL-COBRA are:

Events Affecting Employees and Their Dependents:

• 36 months - Termination of employment or reduction in hours of covered employee.
• When a qualified beneficiary is determined under the Social Security Act to be disabled either; (1) at the time of termination of employment (or reduction in hours), or (2) during the final 60 days of CAL-COBRA continuation coverage, that person and any family members entitled to continuation coverage are eligible for 36 months of continuation after the date the qualified beneficiary's benefits under the contracts would otherwise have terminated because of a qualifying event.

Events Affecting Dependents Only:

• 36 months - Death of the covered employee upon whom the dependent has coverage.
• 36 months - The divorce or legal separation of the covered employee from a covered spouse causing a loss of coverage for the spouse.
• 36 months - Loss of dependent status for a dependent enrolled in the plan.

When CAL-COBRA Coverage Ends

CAL-COBRA coverage will terminate earlier than the applicable continuation period for any of the following reasons:

• At the end of the period in which CAL-COBRA benefits are payable.
• Age 65, for former employees who were at least 60 years of age and coverage ended due to termination of employment and who worked for the employer for at least 5 years.
• Cost of continued coverage is not paid within the grace period as stated in the group Certificate of Insurance (usually 31 days).
• Qualified person becomes eligible for Medicare or becomes covered under another dental plan.
• Plan terminates for all employees or for an employee's class.

Call Customer Service at 1-800-ASK-4-MET (1-800-275-4638) if you have any questions regarding the termination of CAL-COBRA benefits.

Any person who elects to continue coverage under the plan must pay the full cost of that coverage plus any additional amount permitted by law.

DHMO Participants may contact 1-800-880-1800, or send an email to customerserviceinquiry@metlife.com for Benefit Assistance, including: Plan information, Emergency Referrals and Changing Dental Offices.

*Dental HMO or DHMO Plans in CA, FL and TX are available through a domestic company in the applicable state named SafeGuard Health Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. "Dental HMO" or "DHMO" is used to refer to products that may differ by state of residence of the enrollee, including but not limited to: "Specialized Health Care Service Plans" in California; "Prepaid Limited Health Service Organizations" as described in Chapter 636 of the Florida statutes in Florida; and "Single Service Health Maintenance Organizations" in Texas.

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact MetLife for complete details.