Renaissance Individual Dental Plan III Schedule of Covered Services and Copayments
Includes only the coverage you need so you'll never have to pay too much for a healthy smile.
The below summary is a sample of benefits. Policies have exclusions and limitations that may limit coverage. For complete coverage details, please refer to your policy (in Oregon, refer to policy INVD-100A-OR v2). These dental plans are available exclusively to members of organizations offering Renaissance Dental to them.
Underwritten by Renaissance Life & Health Insurance Company of America, Indianapolis, IN, and in New York by Renaissance Health Insurance Company of New York, New York, NY.
Products and services referred to in this site are not available in all states or jurisdictions.
|Renaissance Individual Dental Plan III|
Note: Some procedures in the categories above may be payable at a different benefit level than indicated. The submission of a pre-determination will provide an estimate of patient out-of-pocket expenses.
Plans underwritten by Renaissance Life & Health Insurance Company of America, Indianapolis, IN, and in New York by Renaissance Health Insurance Company of New York, New York, NY.
NOTES: The enclosed summaries are samples of benefits. Policies have exclusions and limitations that may limit coverage. [Renaissance Dental PPO Basic Plan may not be available in all states.] For complete coverage details, please refer to your policy, INVD-100A-ID.
EXCLUSIONS: Cosmetic surgery or dentistry for aesthetic reasons (except reconstructive surgery for children because of congenital disease or anomaly); general anesthesia and/or intravenous sedation; treatment by anyone other than a licensed dentist or dental hygienist; veneers, sealants, prosthodontics (implants), prefabricated crowns as final restoration on permanent teeth and paste-type root canal fillings on permanent teeth; appliances, procedures and restorations for increasing vertical dimension, occlusion, tooth structure loss due to attrition, abrasion or erosion, or for periodontal splinting; orthodontic services; space maintainers; lost, missing or stolen appliances; services not in the Policy and/or Summary of Dental Plan Benefits.
LIMITATIONS: Coverage for services may be limited based on the age of the person receiving services; coverage for certain services may be limited to a maximum number of occurrences during a specified time period (such as two times per year or one time every three years); coverage for temporomandibular disorders (TMD) is limited.
The premium rate will vary between plans. The policy has a term of one year and will automatically renew (upon payment of required premium) unless terminated in accordance with the policy provisions. Coverage may be terminated for reasons stated in the policy. Coverage ceases upon termination of the policy. Products and services referred to in this brochure may not be available in all states or jurisdictions. Underwritten by Renaissance Life & Health Insurance Company of America, PO Box 1596, Indianapolis, IN 46206
|Plan III Covered Services||In Network
|Out of Network
|Class I Benefits|
|Diagnostic and preventive services - Used to evaluate existing conditions and/or to prevent dental abnormalities or disease (includes exams, cleanings, bitewing x-rays and fluoride treatments)||0%||20%|
|Class II Benefits|
|Emergency palliative treatment - Used to temporarily relieve pain||0%||20%|
|Radiographs/Diagnostic Imaging - X-rays as required for routine care or as necessary for the diagnosis of a specific condition||20%||40%|
|Minor Restorative Services - Used to repair teeth damaged by disease or injury (for example, silver fillings and white fillings )||20%||40%|
|Simple Extractions - Simple extractions including local anesthesia, suturing, if needed and routine post-operative care||50%||50%|
|Sealants - Sealants for the occlusal surface of first and second permanent molars||100%||100%|
|Periodontal Maintenance - Periodontal maintenance following active periodontal therapy||20%||40%|
|After Hour Visits - Services performed during after hours visits by a dentist||20%||40%|
|Class III Benefits|
|Oral Surgery Services - Extractions and dental surgery, including local anesthesia, suturing, if needed, and routine post-operative care, services for the diagnosis and treatment of temporomandibular disorders||50%||50%|
|Endodontic Services - Used to treat teeth with diseased or damaged nerves (for example, root canals)||50%||50%|
|Periodontic Services - Used to treat diseases of the gums and supporting structures of the teeth||50%||50%|
|Major Restorative Services - Used when teeth can't be restored with another filling material (for example, crowns)||50%||50%|
|Prosthodontic Services - Used to replace missing natural teeth (for example, bridges and dentures, and certain implant services)||50%||50%|
|Relines and Repairs - Relines and repairs to bridges, removable bridges, partial dentures, and complete dentures||20%||40%|
|Occlusal Guards - Benefits for occlusal guards, and limited occlusal adjustments||50%||50%|
|Office Visits - Office visits during regularly scheduled hours||50%||50%|
|Class IV Benefits|
|Orthodontic Services - Services , treatment, and procedures to correct malposed teeth||100%||100%|
|Method of Benefit Payment
For services rendered by In-Network Dentist, the Allowed Amount are pre-negotiated fees that the provider has agreed to accept as payment in full. Benefit payment will be based on the Allowed Amount method of payment. For Out-of-Network Dentists, RLHICA determines the Allowed Amount based upon treatment rendered and the periodically determined 70 percentile of fees charged by a sample of Dentists of similar training within your geographic area. RLHICA will base Benefit payments on the lesser of the Submitted Amount and the Allowed Amount. If the Submitted Amount for an Out-of-Network Dentist is more than the Allowed Amount, the Insured is not only responsible for paying the Dentist that percentage of the Allowed Amount listed in the “You Pay” column, but is also responsible for paying the Dentist the difference between the Submitted Amount and the Allowed Amount.
- $1000 per person total per Benefit Year on Class I, Class II and Class III Benefits collectively
- $300 per person total per Lifetime for TMD treatment
$50 deductible per person per benefit year limited to a maximum deductible of $150 per family per benefit year. The deductible does not apply to Diagnostic and Preventive services, Emergency Palliative Treatment, Brush Biopsy, and bitewing X-rays.
The Insured, and Eligible Dependents if covered, will be eligible for coverage for the following benefits