Dental policy restrictions

- Pre-existing conditions, wait periods, frequency of service, excluded services, deductibles, yearly benefit maximums. / Possible work arounds for policy limitations.

You can expect to find that your dental coverage has some type of restrictions or exclusions attached to it. This would be especially true in the case of insurance policies and possibly for some discount plans too.

Some of these limitations will involve what dental procedures are covered (pre-existing conditions, excluded services) or when they can be performed (frequency of services, wait-periods). Other restrictions will involve limitations on the amount of benefits paid (deductibles, maximum benefits).

Why do policy limitations exist?

In the case of dental insurance, it's easy enough to understand why some type of limitations must be written into a policy. In order to stay in business a company can't pay out more in benefits than it collects in premiums.

All of the restrictions above are designed as a way of controlling the company's overall expenditures, so it will remain in business to provide benefits for other members too.

A) Does the policy have a "wait" period?

Wait periods are time frames during which certain types of procedures are not covered, or else not covered as fully as they will be after this initial time period has elapsed.

As an example:

  • You may find that during the first six months or year of a new plan's term only preventive dental procedures are covered (exams, cleanings, x-rays).

    More extensive items, such as placing dental crowns or gum surgery, or even just placing fillings, are not.

  • Then, after this initial period has elapsed, the plan becomes more inclusive and provides benefits for these services too.

Depending upon what your immediate dental issues happen to be, this type of wait clause may make a plan unsuitable for your needs.

B) Are there exceptions for pre-existing conditions?

A dental plan may have restrictions regarding "pre-existing conditions." This term, however, doesn't always mean exactly what you might think it does.

Having cavities, teeth that need root canal treatment, or even large fillings that you had always planned to replace with dental crowns don't usually fall under this category.

This term is more likely associated with limitations such as:

  • Not covering dental procedures used to replace teeth that were extracted before the person was covered by their current plan.
  • Excluding coverage for replacing crowns, bridges or dentures that are less than a certain number of years old (often 5 years).
  • The exclusion of benefits for the completion of dental work that was already started before being covered.

C) Are there restrictions on the types of procedures that are covered?

You'll need to confirm that the policy that you're considering provides benefits for the types of dental procedures you require.

Sometimes procedures you'd expect are covered aren't.

It's not unheard of that some plans won't provide coverage for procedures as common as dental crown placement. And white fillings for back teeth are sometimes excluded too. (Although there may be a provision where coverage is provided for them at the same rate as for amalgam fillings, with the patient making up the cost difference.)

More typically, a policy may not provide coverage for dental implants or extensive full-mouth rehabilitation.

It's fairly common that a plan will not cover restorations that are placed solely to repair tooth abrasion, attrition and erosion, or restoring or altering the patient's vertical dimension. This stipulation might affect the benefits expected for some dental crowns, bridges or even some fillings.

Cosmetic procedures are seldom covered by insurance.

Most policies will exclude coverage for procedures that are performed solely for cosmetic reasons.

These types of treatments might include: teeth whitening, porcelain veneers, composite veneers and potentially even some dental crowns, bridges or white fillings. It's less common to see this type of restriction with a discount dental plan.

D) Are there limitations on how often some procedures can be performed?

Certain types of dental procedures may be limited in regard to how often the policy provides coverage for them. As examples:

  • It's common that many Preventive procedures are only covered at certain intervals.

    Cleanings and exams may be limited to either twice-a-year or else every 6 months. Bite-wing x-rays may be covered as frequently as every 6 months, or just once a year. Full-mouth x-rays may be limited to once every several years (3 to 5).

  • The frequency of coverage for some types of Major dental services may be limited. Benefits for dental crown replacement is often restricted to once every 5 years, as are dentures (full or partial).

E) What deductibles are involved with the plan?

You will need to evaluate any deductibles that are associated with the policy you are considering. This is the dollar amount you will have to pay out-of-pocket before the insurance company will provide any benefits for any dental services.

Some types of insurance plans (Indemnity / Traditional, PPO's) typically do have some sort of deductible, possibly along the line of $50 to $100 per individual (but the exact amount can certainly be more or less than this).

Dental HMO's typically don't require the payment of a deductible.

You'll need to understand how it's calculated.

If a deductible is involved, there are a few questions you should investigate.

  • Is it calculated just on a per-member basis or is there some type of cumulative per-family deductible?
  • Will any portion of a deductible paid late in one policy year apply to the next year's?
  • Does the deductible apply to all types of dental treatments or are some services (such as Preventive ones) exempted?

F) What is the maximum yearly benefit that the plan will provide?

You will need to evaluate an insurance plan's maximum dollar benefit. This is typically stated in terms of a yearly maximum. For some dental procedures (frequently orthodontic treatment), there may be a lifetime dollar limitation also.

(Note: You'll need to determine what time basis is involved. Is it a calendar year, or else a year's time frame that starts on the day the plan becomes effective?)

Common limitations.

Maximum limits are frequently seen with traditional (indemnity) and PPO insurance plans. It often ranges between $750 and $2000 per year but this value will absolutely vary with each policy, so you'll have to check.

Capitation programs (dental HMO's) typically don't have a maximum benefit limitation.

You'll need to understand how this limit is calculated.

Remember, this number represents the maximum total benefit that the insurance company will pay, not the total value of the dental work received.

Benefits for some procedures, like Basic and Major services, may only be paid at 80 to 50%. If this is the case, then only a portion of their cost (the part the insurance company actually pays) will be applied to the calculation of the patient's maximum benefit limitation.

Creative treatment planning.

You may find that the maximum benefits limitation of the policy you have is relatively small compared to your dental needs.

If so, don't overlook the possibility of breaking your treatment into two parts, one of which is initiated at the end of one benefits year and the other a few days later but in the next. (Your dentist will need to check to see what's allowed but usually claims are based on the date on which the procedure was initiated, not completed.)

Doing so can help to keep your total costs low, while your dental work is still started and completed within a relatively normal and convenient time frame.



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