Dental Insurance - American Health Shield PPO Plan Details

Renaissance Life & Health Insurance Company of America

Renaissance Dental PPO - American Health Shield Plan P
Summary of Dental Plan Benefits
For Group#8850
American Travel Services Trust

This Summary of Dental Plan Benefits should be read in conjunction with your Preferred Provider Dental Benefits Certificate. Your Preferred Provider Dental Benefits Certificate will provide you with additional information about your Renaissance Dental Plan, including information about plan exclusions and limitations.

Benefit Year – 12 month period beginning with covered person’s effective date.

Covered Services -	In-Network		Out-of-Network
Covered Services -	RLHICA Pays	You Pay	RLHICA Pays	You Pay
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)	100%	0%	100%	0%
Class II Benefits
Emergency Palliative Treatment - Used to temporarily relieve pain	80%	20%	60%	40%
Radiographs/Diagnostic Imaging - X-rays as required for routine care or as necessary for the diagnosis of a specific condition	80%	20%	60%	40%
Minor Restorative Services – Used to repair teeth damaged by disease or injury (for example, silver fillings and white fillings)	80%	20%	60%	40%
Simple Extractions – Simple extractions including local anesthesia, suturing, if needed and routine post-operative care	80%	20%	60%	40%
Sealants – Sealants for the occlusal surface of first and second permanent molars	Not Covered	100%	Not Covered	100%
Periodontal Maintenance – Periodontal maintenance following active periodontal therapy	80%	20%	60%	40%
After Hour Visits – Services performed during after hours visits by a dentist	80%	20%	60%	40%
Consultations – Benefits for consultations by a dentist other than the practitioner providing treatment	80%	20%	60%	40%
Class III Benefits
Oral Surgery Services – Extractions and dental surgery, including local anesthesia, suturing, if needed, and routine post-operative care	50%	50%	40%	60%
Endodontic Services – Used to treat teeth with diseased or damaged nerves (for example, root canals)	50%	50%	40%	60%
Periodontic Services – Used to treat diseases of the gums and supporting structures of the teeth	50%	50%	40%	60%
Major Restorative Services – Used when teeth can't be restored with another filling material (for example, crowns)	50%	50%	40%	60%
Prosthodontic Services – Used to replace missing natural teeth (for example, bridges, dentures, and implant services)	50%	50%	40%	60%
Relines and Repairs – Relines and repairs to bridges, removable bridges, partial dentures, and complete dentures	50%	50%	40%	60%
Occlusal Guards – Benefits for occlusal guards, and limited occlusal adjustments	50%	50%	40%	60%
Office Visits – Office visits during regularly scheduled hours	50%	50%	40%	60%
Class IV Benefits
Orthodontic Services – Services, treatment, and procedures to correct malposed teeth including Orthodontic Services for Children to the age of 19	50%	50%	50%	50%

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 80th 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 Certificate Holder 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.

Maximum Payment – $2000 per person total per benefit year on Class I, Class II and Class III Benefits collectively. $1000 per person total per Lifetime on Class IV Benefits.

Deductible - $50 deductible per person per benefit year on Class II and Class III Benefits. The deductible does not apply to Class I or IV Benefits.

Waiting Period – All Certificate Holders (and their Dependents, if covered above) will be eligible for coverage for Class II Benefits 6 months following the effective date of the Certificate Holder or Dependent.

All Certificate Holders (and their dependents, if covered above) will be eligible for coverage for Class III Benefits 12 months following the effective date of the Certificate Holder or Dependent.

All Dependents under age 19, (if covered above) will be eligible for coverage for Class IV Benefits 24 months following the date the dependent enrolled.

Eligible Certificate Holder – All bonafide members of the American Travel Services Trust who enroll in the voluntary dental Plan underwritten by RLHICA. Also eligible are your legal spouse, your dependent unmarried children to the end of the calendar year in which they turn 19 or your children who have not yet reached the end of the calendar year of their 25th birthday, if the child is (1) dependent upon you for support and (2) is a full-time student or part-time student.

The Certificate Holder pays the full cost of this Plan.

Benefits will cease on the last day of the month for which payment is made, subject to all applicable laws or regulations.

Long Term Consumer Care, Inc.
N27 W23960 Paul Road Suite 201 ~ Pewaukee, WI 53072
Toll Free: 1.800.544.9505 Fax: 1-262.523-1910