Plan Administrator: Independence Holding Company IHC | AM Best Rating: A-"Excellent" | Underwriter: Madison National Life Insurance Company in all states except Maine, New Hampshire and New York where it is underwritten by Standard Security Life Insurance Company of New York.
Apex |
Bay |
Ridge1 |
|
| Plan type | PPO2 | PPO2 | Indemnity2 |
|
Deductible, Applies per covered person, per calendar year to all services |
$50 | $50 | $100 lifetime |
| Maximum benefit per calendar year | $1,000 | $1,000 |
First plan year: $500 Second plan year: $750 Third plan year and thereafter: $1,000 |
| Percentage paid by the plan after deductible: | |||
|
Preventive care - Office visit - Cleaning - Topical fluoride - Sealants |
100% 100% 80% 80% |
100% 100% 100% 100% |
80% 80% 80% 80% |
|
Diagnostic care X-rays |
80% after 6 month waiting period | 100%, no waiting period | 60% |
|
Basic care Restorative dentistry/fillings, extractions |
80% after 6 month waiting period | 50% after 6-month waiting period | 40% after 3 month waiting period |
|
Major care Crowns, bridges, dentures, root canals, periodontics, endodontics and oral surgery |
50% after 12 month waiting period | Not covered3 | 20% after 15 month waiting period |
1 “Oral Health: A Window to Your Overall Health.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 5 Feb. 2011. Web. 25 Mar. 2011. http://www.mayoclinic.com/health/dental/DE00001.
2 Out-of-network charges in excess of the network reimbursement schedule are the responsibility of the insured person.
3 Although not covered under the plan, a discount may be available at network providers for basic and major care services.
Discounts are available at the provider’s discretion where not prohibited by law. Apex and Bay plans are not available in the states of Idaho, Massachusetts, New Jersey and North Carolina.
1 This plan is not available in the states of Colorado, Kentucky, Michigan, Minnesota, Missouri, New Jersey, Ohio and Rhode Island.
2 Claims reimbursement is subject to the Reasonable and Customary Charge. Billed charges in excess of this amount are the insured person’s responsibility.
Benefits paid for the services listed below are based on the plan selected.
(Limits reflected below are per covered person)
Preventive care
Diagnostic care
Basic care
Major care
Optional orthodontia discounts
OrthoCare is an optional discount program that may provide savings of 15–20 percent on services performed by a contracted OrthoCare orthodontist.
The OrthoCare Program is not an insurance benefit, nor is it affiliated with Madison National Life or Standard Security Life as a part of the IHC Dental insurance plan. The OrthoCare Program is not available in all states.
Coordination of benefits
This plan will be coordinated with any other group, blanket or franchise plan under which an individual will receive benefits.
Alternative benefit
If we determine that a less expensive service or supply can be used in place of the proposed treatment based on broadly accepted standards of dental care, benefits are limited to the Reasonable and Customary Charge for the least expensive alternative treatment.
Predetermination of benefits
Except in an emergency, before a covered person may begin treatment that will cost more than the predetermination amount shown on the schedule of benefits, the dentist must submit a claim to us describing the treatment necessary and the cost. This estimate is not a guarantee of payment. We will still consider a claim for which the covered person has not obtained prior approval; however, the claim will be subject to reduced benefits based on our determination of Reasonable and Customary Charge, and medically necessary treatment.