Gap Dental Plan
Member Driven Value.
Summary of Plan
Broad Coverage for Brighter Smiles
50% of Americans are without dental insurance. And 74% of people without dental insurance see a dentist only when they have a perceived problem.1
40.2% of adults indicated that they will forgo dental care due to cost.2
Stats taken from: 1http://www.statisticbrain.com/dental-hygeine-statistics/. 2Health Policy Institute (ADA American Dental Association) http://ada.org/en/science-research/health-policy-institute/dental-statistics/patients.
| Annual Deductible: Individual / Family
(Deductible waived for Diagnostic & Preventive Services)
|$50 / $150|
| Annual Maximum
Plus Maximum Carryover^
^If at least one covered service is paid in a benefit year and the total benefit paid does not exceed $500 in that benefit year, $250 will be added to the next benefit year carryover maximum. The amount will accumulate from one benefit year to the next, but will not exceed $1,000.
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
SAVE ON THE CARE YOU NEED^
For Example: A dentist may submit a $950 charge for a crown. With dental insurance, the dentist accepts a reduced fee of $744. That's an immediate savings of $206! Furthermore, having dental insurance means the carrier pays a percentage from the reduced fee so you can see how the advantages of dental coverage can add up quickly.
For An In-Network Dentist^
SUBMITTED FEE: $950
MAX APPROVED FEE
|YOU PAY: $372
61% decrease from the dentists fee!
Coverage is available to paid Members of the United Business Association after the effective date listed in your welcome letter following the receipt of the Membership application and the payment of the first month's dues to the United Business Association.
Dental benefits are 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. Both companies can be reached at PO Box 1596, Indianapolis, IN 46206. This information is a brief description of the important features of this insurance plan. It is not an insurance contract. For more details, limitations, exclusions and definitions, please refer to the Certificate.
Difference Between In- & Out-of-Network Benefits
100% COINSURANCE - In- or Out-of-Network
Diagnostic & Preventive Services Include:
Twice / 12 Mos
Twice / 12 Mos
X-Rays - Bitewing5
To Age 19
Twice / 12 Mos
To Age 16
Once / 36 Mos
*Diagnostic & Preventive Services also include Oral CDx BrushTest®, an oral Brush Biopsy that can detect precancerous cells and oral cancer in its earliest stages to its benefit plans. Renaissance Dental pays the approved percentage of the fee for both the BrushTest procedure and the laboratory analysis for covered patients.
3People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment. (See below Evidence Based Dentistry).
4Full Mouth X-rays are payable once in any 5 year period.
5Bitewing X-Rays are payable once per benefit period
6Sealants are payable only for the occulusal surface of the first and second permanent molars to age 16. The surface must be free from decay and restorations. Sealants are payable once per tooth per 3 year period.
Evidence Based Dentistry:
Renaissance Dental has enhanced its benefit plans to accommodate members who are at higher risk for serious illnesses. Covered cleanings will increase from two to four annually for persons with certain high-risk medical conditions, including those experiencing kidney failure or who are undergoing dialysis; diabetics with periodontal disease; pregnant women with periodontal disease; those susceptible to infective endocarditis; and those with suppressed immune systems due to chemotherapy and / or radiation treatment, HIV infection, organ transplant, and / or stem cell (bone marrow) transplant. Talk to your dentist if you have any of these conditions, and contact Renaissance to find out if you are eligible for these additional benefits. Your dentist must provide a notation on your claim to receive full reimbursement.
70% COINSURANCE - In- or Out-of-Network
Basic Services Include:
*Plus other basic services (miscellaneous services).
7Minor Restorative Services
9To treat gum disease - we allow for two cleanings or two perio maintenance visits, or a combination of both but no more than two in a benefit year.
10To temporarily relieve pain
50% COINSURANCE - In- or Out-of-Network
Major Services Include:
(I.E. ROOT CANALS)
& DENTAL SURGERY12
RELINES & REPAIRS OF
BRIDGES & DENTURES
*There is a 12 month waiting period for all members on Major Services.
11To treat gum disease
12All Other Oral Surgery Services
13Treatment of Temporomandibular Joint Dysfunction - Treatment is limited
14Major Restorative Services (Crowns & Veneers are payable once per tooth per 5 year period)
15Prosthodontic Services (Bridges & Dentures are payable once per tooth per 5 year period; Implants are payable once per tooth per lifetime)
Gap Dental Plan CostsThe following monthly insurance rates apply to coverage underwritten by Renaissance Life & Health Insurance Company of America and Renaissance Health Insurance Company of New York. Your overall total association membership dues include these insurance rates:
|Area 1: AL, AR, LA, MS, WV
Area 2: GA, KS, MO, NE, SC, TX, WY
|Area 3: IL, KY, OK, TN
Area 4: AZ, DC, FL, IA, IN, ND, NJ, NM, NV, OH, PA, RI, UT, VA & WI
|Area 5: DE, MI, NC
Area 6: ID
|Area 7: CA
Gap Dental Plan is Available in the Following States:
AZ, GA, KS, MI, OK, TN & TX
Gap Dental Plan Insurance Certificates
Please check back for Gap Dental Certificates to be viewed here soon.
For Claims Assistance, Contact:
United Business Association Claims Unit
Renaissance Life & Health Insurance Company of America
PO Box 17250, Indianapolis, IN 46217
Eligibility & Benefit Info: 888.358.9484
Benefit payment is subject to the plan provisions, limitations, exclusions and other provisions within the Certificate. For more information and complete details of terms, conditions, limitations, and exclusions of coverage, please refer to the Certificate. Coverage may vary and may not be available in all states. Renaissance Life & Health Insurance Company of America and Renaissance Health Insurance Company of New York, New York, NY do not provide nor is affiliated with the discount programs provided as part of membership in the United Business Association.
Find a Dental Provider in the Network
You can receive dental services from any licensed dentist; however your benefit dollars may stretch even further if services are obtained from a participating PPO network dentist. The Renaissance Dental PPO network combines leading national and regional networks to offer you maximum choice and value. Members can search for a participating dentist at www.RenaissanceDental.com/FindADentist. If you decide to contact a dental office directly, please refer to the following network partners that a dental office will likely recognize:
- Maximum Care
- Connection Dental
For Group Dental Insurance
Renaissance Does Not Pay Benefits For:
1. Services for injuries or conditions which are compensable under Workers’ Compensation or Employer’s Liability laws; services which are provided to the Enrollee by any federal or state government agency or are provided without cost to the Enrollee by any municipality, county or other political subdivision except as such exclusion may be prohibited by law.
2. Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration) of the teeth, and andontia (congenitally missing teeth), except those services provided to newborn children for congenital defect or birth abnormalities or services that may be provided under Orthodontic Benefits.
3. Services for restoring tooth structure lost from wear, erosion, or abrasion, for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Such services include, but are not limited to: equilibration, periodontal splinting, occlusal adjustment.
4. Any single procedure started prior to the date the person became covered for such services under this plan.
5. Prescribed drugs, medication or analgesia.
6. Experimental Procedures.
7. Charges for any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in such a facility.
8. Charges for anesthesia, other than by a licensed Dentist for administering general anesthesia in connection with covered oral surgery services.
9. Extra oral grafts (grafting of tissues from outside the mouth to oral tissue).
10. Services performed by any person other than a Dentist or auxiliary personnel legally authorized to perform services under the direct supervision of a Dentist.
11. Replacement of teeth extracted prior to the member’s effective date.
12.Services or appliances started prior to the covered person’s effective date; Treatment by anyone other than a dentist or licensed dental hygienist; Services received from any governmental agency, political subdivision, community agency, foundation or similar entity other than Medicaid; Tests and laboratory examinations; Medications and prescription drugs; Charges related to hospitalization or general anesthesia and / or intravenous sedation; Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared; Cosmetic Surgery or dentistry for aesthetic reasons; Dental services that are specialized techniques or investigational in nature.
13. 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 2 times per year, or 1 time every 3 years); Coverage for temporomandibular disorders (TMD) is limited.
The above is a summary of exclusions and limitations. For complete details, please refer to your Certificate. Not all coverage provided under the Certificate is set forth above. The Certificate term is one year. Coverage may be terminated for reasons stated in the Certificate. Coverage ceases upon termination of the Certificate.
If insurance is included in any Gap Plan, it is not basic health insurance or major medical coverage and does not qualify as minimum essential coverage under the Affordable Care Act. You must be a member of the United Business Association (UBA) to access and enroll in any Gap Plan that provides an insured benefit. Various insurance companies, as described, have issued group limited benefit insurance policies to the United Business Association as the group master policyholder. You must purchase UBA Membership in order to purchase this additional plan.
UBA Refund / Cancellation Policy
If you are not completely satisfied with your UBA Gap Plan, please call your Personal Member Concierge at 866.438.4274. We will be happy to issue a complete refund of membership dues within the first thirty (30) days. We want you to be 100% satisfied with your UBA Gap benefits and services.
Note: This membership is separate from any other insurance or supplemental plan you have purchased. Please contact your agent for any plans other than the UBA Gap Membership Plan. If you are canceling, please make sure to cancel using our cancellation phone number at 866.438.4274 or our cancellation form located at gapplusplan.com/billing.html. Please do not cancel through your agent. Cancel directly with UBA to make sure your cancellation request is handled promptly and correctly.