Exclusions, Limitations, Predetermination of Benefits & Termination | Contractual Provisions

Exclusions

Exclusions are found in all dental plans, but their number and type vary. Some of the more common exclusions are charges for the following:

• Services that are purely cosmetic, unless necessitated by an accidental bodily injury while a person is covered under the plan (Orthodontics, although often used for cosmetic reasons, can usually also be justified as necessary to correct abnormal dental conditions.)

• Replacement of lost, missing, or stolen dentures or other prosthetic devices

• Duplicate dentures or other prosthetic devices

• Oral hygiene instruction or other training in preventive dental care

• Services that do not have uniform professional endorsement

• Occupational injuries to the extent that benefits are provided by workers' compensation laws or similar legislation

• Services furnished by or on behalf of government agencies, unless there is a requirement to pay

• Certain services that began prior to the date that coverage for an individual became effective (e.g., a crown for which a tooth was prepared prior to coverage)

Limitations

Dental insurance plans also contain numerous limitations that are designed to control claim costs and to eliminate unnecessary dental care. In addition to deductibles and coinsurance, virtually all dental plans have overall benefit maximums. Except for DHMOs, which usually do not have a calendar-year limit, most plans contain a calendar-year maximum (varying from $500 to $2,000) but no lifetime maximum. However, some plans have only a lifetime maximum (such as $1,000 or $5,000), and a few plans contain both a calendar-year maximum and a large lifetime maximum. These maximums may apply to all dental expenses, or they may be limited to all expenses except those that arise from orthodontics (and occasionally periodontics). In the latter case, benefits for orthodontics are subject to a separate, lower lifetime maximum, typically between $500 and $2,000.

Most dental plans limit the frequency with which some benefits are paid. Routine oral examinations and teeth cleaning are usually limited to once every six months, and full-mouth X-rays to once every 24 or 36 months. The replacement of dentures may also be limited to one time in some specified period (such as five years).

The typical dental plan also limits benefits to the least expensive type of accepted dental treatment for a given dental condition. For example, if either a gold or silver filling can be used, benefit payments will be limited to the cost of a silver filling, even if a gold filling is inserted.

Predetermination of Benefits

About half of dental contracts provide for a pretreatment review of certain dental services by the insurance company. Although this procedure is usually not mandatory, it does allow both the dentist and the patient to know just how much will be paid under the plan before the treatment is performed. In addition, it enables the insurance company (or other provider of benefits) to have some control over the performance of procedures that are unnecessary or more costly than necessary, by giving patients an opportunity to seek less costly care (possibly from another dentist) if benefits will be limited.

In general, the predetermination-of-benefits provision (which goes by several names, such as precertification or prior authorization) applies only in nonemergency situations and when a dentist's charge for a course of treatment exceeds a specified amount (varying from $200 to $300). The dentist files a claim form (and X-rays, if applicable) with the insurance company just as if the treatment had already been performed. The insurance company reviews the form and returns it to the dentist. The form specifies the services that will be covered and the amount of reimbursement. If and when the services are actually performed, payment is made to the dentist by the insurance company after the claim form has been returned with the appropriate signatures and the date of completion.

When the predetermination-of-benefits provision has not been followed, benefits are still paid. However, neither the dentist nor the covered person knows in advance what services will be covered by the insurance company or how much the insurance company will pay for these services.

Termination

Coverage under dental insurance plans typically terminates for the same reasons it terminates under medical expense coverage. Rarely is there any type of conversion privilege for dental benefits, even when the coverage is written as part of a major medical contract. However, dental coverage is subject to the continuation rules of COBRA.

Benefits for a dental service received after termination may still be covered as long as (1) the charge for the service was incurred prior to the termination date and (2) treatment is completed within 60 or 90 days after termination. For example, the charge for a crown or bridgework is incurred once the preparation of the tooth (or teeth) has begun, even though the actual installation of the crown or bridgework (and the billing) does not take place until after the coverage terminates. Similarly, charges for dentures are incurred on the date the impressions for the dentures are taken, and charges for root canal therapy are incurred on the date the root canal is opened.