NESA Dental and Vision Benefit Plan
Benefits Experience that Stands Out
NESA in partnership with Consolidated Insurance and Renaissance Corp, is pleased to announce the official rollout of the NESA Dental Plan with optional vision benefits¹, as of May 15th for effective dates beginning June 1, and after.
¹ Dental and vision products are marketed by Consolidated Insurance and underwritten by Renaissance Life & Health Insurance Company of America, Indianapolis, IN, and in New York by Renaissance Life & Health Insurance Company of New York, Binghamton, NY. Both companies may be reached at PO Box 1596, Indianapolis, IN 46206. Access to the benefits are included with membership in your NESA State Association.
HOW TO ENROLL
IN NESA BENEFIT PLANS
For Further Questions Or To Enroll Please Contact Your NESA Representative At Consolidated Insurance:
- Mary Hesse – 443.738.2747
- Denise Jones – 443-738-2782
- email it to email@example.com
- fax it to: 410-654-8886
- Date of Birth
- Date of Birth
OUR DENTAL PLAN OPTIONS INCLUDE:
- No waiting periods for benefits
- Option to start coverage the first of the month after enrollment
- Routine cleanings paid at 100%
- Basic services like fillings, sealants and extractions
- Major services like crowns, oral surgery & implants
- Orthodontia option available for children under 19
With Renaissance coverage you have the freedom to visit any licensed dentist. Plus, you have access to a
national network of preferred providers who have agreed to accept lower rates as full payment for covered
services. Advantages to choosing an in-network provider include:
- No Paperwork! Your dentist fills out all forms and files claims for you.
- No Extra Charges! You only have to pay your deductible and/or your co-insurance charges for covered services.
- No Balance Billing! Balance billing for covered services means you’ll never pay more than the allowed fees.
- No Paying Full Price! You won’t have to pay full price for your dental visits OR wait for reimbursement.
RENAISSANCE DENTAL PLANS PROVIDE WIDESPREAD ACCESS TO CARE:
Our dental plan has access to over 300,000 nationally credentialed PPO dental office locations.* While you may save the most money by visiting a dentist in our vast network, you are welcome to visit any licensed dentist in the country. Find a dentist at MyRenProvider.com.
*Renaissance Internal Data, 2019
Dental Benefits Overview
|DENTAL||OPTION A||OPTION B|
|Preventive/ Diagnostic Services*||Insurance pays||Insurance pays|
|Exams – every 6 months||100%||100%|
|Prophylaxis (cleaning) – 2 per year||100%||100%|
|Bitewing X-ray – 1 set per year||100%||100%|
|Fluoride to age 19- 1 per year||100%||100%|
|Benefit year deductible||$50 per person, $150 per family||$50 per person, $150 per family|
|BASIC SERVICES*||INSURANCE PAYS||INSURANCE PAYS|
|Sealants to age 16||80%||80%|
|Space maintainers to age 14||80%||80%|
|MAJOR SERVICES*||INSURANCE PAYS||INSURANCE PAYS|
|Crowns, bridges, dentures||50%||50%|
|BENEFIT YEAR MAXIMUM||$1,000||$1,500|
|ORTHODONTIA**||INSURANCE PAYS||Insurance pays|
|Children to Age 19||50%||50%|
|Orthodontia lifetime maximum||50%||$1,000|
|ALLOWED AMOUNTS||ALLOWED AMOUNTS|
|In-network providers||Negotiated PPO network fee||Negotiated PPO network fee|
|Out-of-network providers||Negotiated PPO network fee||90th percentile†|
Under the Low Plan, eligible dental charges from providers not participating in the designated PPO networks will be reimbursed no higher than the PPO allowed amount. The insured is responsible for any provider charges billed over the allowed amount in addition to “you pay” amounts identified in the summary of benefits. † Under the High Plan, eligible dental charges by providers not participating in the designated PPO network are reimbursed based on Renaissance Life & Health Insurance Company of America’s determination of a maximum allowed amount that is representative of the 90th percentile of usual charges for services in the same geographic area. Please refer to the summary of dental
benefits in the certificate for details. * Deductible applies to these services. ** Child only orthodontia for dependents under the age of 19.
Adding vision coverage to your dental plan couldn’t be easier. Members can select the option to bundle dental and vision for one low budget-friendly rate. Vision coverage is administered by VSP®. With over 78 million members and more than 36,000 doctors, VSP® boasts the most extensive doctor network of any vision company.* Eye care professionals across the nation partner with VSP® to deliver the best patient experience. You’ll be thrilled by the large selection of eyewear available to you, from classic styles to trendy frames, you’ll find hundreds of options. Frames include dozens of top brand names, so you can find one that fits your personality.
The best eye doctors provide the best care. VSP® carefully chooses eye doctors based on their professional licensing, work history, education, professional liability and ethics. Vision members will receive quality care with an eye exam from a VSP® doctor.
- When it comes to your health, you deserve the best care. That’s why VSP only partners with highly credentialed eye care professionals—so you’ll receive quality care for all your vision needs.
- ABO Certified: Optometrists are Therapeutic Pharmaceutical Agent (TPA) certified and Ophthalmologists are American Board of Ophthalmology (ABO) certified.
- Excellent Standards: The process VSP uses for credentialing complies with the National Committee for Quality Assurance (NCQA) standards.
- In-Network Providers: There are no claim forms to complete when you see a VSP network doctor. At your appointment, just tell them your coverage utilizes the VSP network.
- Out-of-Network Providers: Not all vision plans administered by VSP provide out-of-network benefit coverage. To see what your plan offers for out-of-network coverage please visit vsp.com and go to the “Benefits & Claims” section. If your plan allows you to see an out-of-network provider, your coverage will be lower and you’ll likely have higher out-of-pocket costs. You’ll also need to submit a claim to VSP for reimbursement.
- Submitting An Out-Of-Network Claim: Simply visit vsp.com and go to the “Benefits & Claims” section. You can submit a claim online or download a form and follow the directions to submit by mail.
. ** VSP Internal Data, 2019
Vision Benefits Overview
|COVERED SERVICE||IN-NETWORK||OUT-OF- NETWORK||FREQUENCY*|
|Eye Exam||$20 copay and includes prescription eyeglasses||Up to $45||12 months|
|Lenses||Covered with eye exam||12 months|
|Single||Covered with eye exam||Up to $30||12 months|
|Bifocal||Covered with eye exam||Up to $50||12 months|
|Trifocal||Covered with eye exam||Up to $65||12 months|
|Lenticular||Covered with eye exam||Up to $100||12 months|
|Frames||Covered with eye exam up to $150 of allowable charges||Up to $70||24 months|
|Contact Lenses**||Exam and fitting, $60 copay up to
$150 of allowable charges
|Up to $105||12 months|
|Low Vision||Professional services for severe visual problems||12 months|
|Testing||Covered in full||Up to $125||24 months|
|Supplemental Aids||75% covered up to $1,000||75% covered up to $1,000||24 months|
* Maximum benefit from the first date of service ** Contacts are in lieu of glasses
OUR OPTIONAL VISION PLAN INCLUDES:
- One exam every benefit period
- Exams, contacts, and frames covered in full if in-network (subject to co-pays and maximums)
- Low vision benefits – professional services for severe visual problems
Who is Consolidated Insurance + Risk Management?
Consolidated Insurance is a highly-respected agency specializing in employee benefits, commercial, and personal insurance. In business since 1938, Consolidated has grown in size and innovation and prides itself on offering practical risk management advice. Our agency has a passion for understanding and capturing client stories. These stories are what inspire us to do what we do every day. It is what drives us to provide comprehensive and competitive insurance products and offer innovative and practical risk management advice to our customers.
As an executive of your organization, you face many obstacles. One of the most challenging parts of your job is managing the risks you know are lurking around each and every corner. An even greater challenge is identifying emerging risks which you did not know existed in the first place.
At Consolidated, we take the time to understand where you have come from and where you are going. After embracing your story, our process is designed to put you in control of the existing and emerging risks attempting to prevent your business from reaching its objectives..
Your story is your life. There are no two lives in this world quite the same. Each has its own individual story. While some in the insurance industry would like you to believe there is a one size fits all product made for you and everyone else, we are here to tell you they are wrong.
At Consolidated, we believe you have your own story with your own risks. The only way to reach your happily ever after while navigating the plot twists of life is to craft protection that is specific to you and no one else.
Who is Renaissance?
Renaissance underwrites the Brilliant Dental™ and vision plans and is part of the Renaissance Health Service Corporation, which has more than 60 years of experience and collectively provides dental coverage for more than 13.1 million people paying out nearly $3 billion for dental care annually.*
Renaissance works hard to provide a benefits experience that stands out. Our evidence-based plan designs combine with our U.S.-based customer service team to provide outstanding benefits and support. Plus, Renaissance members have access to our online portals that allow them to easily manage their benefits information.
*Renaissance Internal Data, 2019
DENTAL EXCLUSIONS AND LIMITATIONS
In addition to the exclusions listed above in the Benefits Section, RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA (RLHICA) will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits Section:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services that are received from any government agency, political subdivision, community agency, foundation or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the date the person became eligible under This Plan, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by RLHICA;
- Services, items or supplies that are specialized techniques, as determined by RLHICA;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by RLHICA;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license or other licensed provider;
- Services, items or supplies excluded by the policies and procedures of RLHICA;
- Services, items or supplies which are not rendered in accordance with accepted standards of dental practice, as determined by RLHICA;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of RLHICA coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical or prescription drug program;
- Services, items or supplies that are not within the categories of Benefits that have been selected by your organization and are not covered in This Plan;
- Prescription drugs, non-prescription drugs, premedications, localized delivery of chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustments,
enamel microabrasions, odontoplasty or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by RLHICA;
- Any appliance or surgical procedure used to: (a)change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; or (d) splint or stabilize teeth for periodontal reasons.
In addition to the limitations listed above in the Benefits Section, the following limitations apply under This Plan, unless otherwise specified in the Summary of Dental Plan Benefits Section:
- RLHICA’s obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under This Plan;
- When services in progress are interrupted and completed later by another Dentist, RLHICA will review the claim to determine the amount of payment, if any, to each Dentist;
- 3. Care terminated due to the death of a Certificate Holder or Eligible Dependent will be paid to the limit of RLHICA’s liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits Section;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits Section, RLHICA will not be obligated to pay, in whole
or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.
VISION EXCLUSIONS AND LIMITATIONS
Some brands of spectacle frames may be unavailable for purchase as Benefits, or may be subject to additional limitations. Covered Persons may obtain details regarding frame brand availability from their In- Network Provider or by calling the Member Services Department at 1-800-877-7195.
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the additional costs for the options. Optional cosmetic processes; Anti-reflective coating; Color coating; Mirror coating; Scratch coating; Blended lenses; Cosmetic lenses; Laminated lenses; Oversize lenses; Polycarbonate lenses; Photochromic lenses, tinted lenses except Pink #1 and Pink #2; Progressive multifocal lenses; UV (ultraviolet) protected lenses; Certain limitations on low vision care.
There are no Benefits for professional services or materials connected with:vices, items or supplies to which the Deductible applies, until the Deductible amount is met.
- Orthoptics or vision training and any associated supplemental testing. Plano lenses (less than a ± .50 diopter power).
- Two pairs of glasses in lieu of bifocals.
- Replacement of lenses and frames furnished under this Plan that are lost or broken, except at the normal intervals when services are otherwise available.
- Medical or surgical treatment of the eyes.
- Corrective vision treatment of an Experimental Nature.
- Costs for services and/or materials above stated allowances.
- Services and/or materials not indicated on this Schedule as covered Plan Benefits. Contact lens modification, polishing or cleaning.
- Local, state and/or federal taxes, except where RLHICA or its claims administrator is required by law to pay. 8. Replacement of lost or damaged contact lenses, except at the normal intervals when services are otherwise available.