Dental
JL Marine Systems offers 2 dental plan options through Guardian. These plans are both PPO plans and allow you to use in-network or out-of-network benefits. If out-of- network dentists are used, you will be responsible for paying the difference between Guardian’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plans.
LOW PPO Dental Plan
HIGH PPO Dental Plan
IN-NETWORK CALENDAR YEAR DEDUCTIBLE (applies to basic and major services only) Individual $50
$50
$150
$150
Family
ANNUAL MAXIMUM (maximum Guardian will pay towards claims per year) Per covered person $1,000
$1,500
DIAGNOSTIC & PREVENTIVE Exams, Cleanings (2 in 12 months), X-Rays, Sealants, etc. BASIC SERVICES Amalgam Fillings, Extractions - Single Tooth MAJOR SERVICES Crowns,Bridges & Dentures, General Anesthesia
Covered in full
Covered in full
20% after deductible
20% after deductible
50% after deductible
50% after deductible
ORTHODONTICS Children Only (up to 19 years old) OUT-OF-NETWORK 1 CALENDAR YEAR DEDUCTIBLE
25% Lifetime Maximum: $500
50% Lifetime Maximum: $1,000
$50 / $150
$50 / $150
ANNUAL MAXIMUM
$500
$1,500
SERVICES Diagnostic & Preventive Basic Major Orthodontics (child only)
100% 20% after deductible 50% after deductible 75% after deductible
100% 80% after deductible 50% after deductible 50% after deductible
Cost for coverage
Weekly $5.50 $12.75 $15.76 $23.06
Bi-Weekly
Weekly $5.91 $13.71 $18.51 $26.35
Bi-Weekly
Employee
$11.01 $25.51 $31.52 $46.12
$11.83 $27.41 $37.02 $52.70
Employee + Spouse Employee + Child(ren) Employee +Family
1 Subject to balancebilling. Please refer to your plan document for specific details.
Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account (MRA). If you reach your Plan Annual Maximum in future years, you can use money from your MRA. To qualify for an MRA, you must have a paid claim (not just a visit) and must not have exceeded the paid claims threshold during the benefit year. Your MRA may not exceed the MRA limit. You can view your annual MRA statement detailing your account and those of your dependents on www.guardiananytime.com.
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