Dental insurance restrictions: Pre-existing conditions, wait periods, excluded services, deductibles, maximums.

You can expect to find that your dental plan (dental insurance / discount plan) has some type of restrictions or exclusions attached to it.

Some of these limitations will involve restrictions on what dental procedures are covered (Pre-existing conditions, Excluded services) or when they can be performed (Wait-period restrictions). Other restrictions will involve limitations on the amount of benefits paid (Deductibles, Maximum benefits).


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.

Long wait periods can present problems.

As an example, you may find that during the first six months or year of a new dental plan's term only preventive dental procedures are covered. More extensive items, such as placing dental crowns or gum surgery, or even just placing filings, are not. Then, after the initial wait period has elapsed, the plan becomes more inclusive and covers these services.

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


B) Does the policy you are evaluating make 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 are known to need root canal treatment, or even teeth that have large fillings whose plan has always been to replace them with dental crowns aren't usually considered to be pre-existing conditions.

This term is more likely associated with restrictions such as not covering dental procedures used to replace a tooth that was extracted before the person was covered by their current plan. The exclusions of benefits associated with replacing a dental crown, bridge or denture that is less than a certain number of years old. Or excluding the completion of dental work that has already been started.


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 that you require.

Sometimes procedures you'd expect should be covered aren't.

It's not typical, but also not unheard of, that some plans won't provide coverage for procedures as common as dental crown placement. More typically, a policy may not provide coverage for dental implants or extensive full-mouth rehabilitation.

It's fairly common that an insurance policy will not cover restorations that are placed solely to repair tooth abrasions, 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 dental insurance policies will exclude coverage for restorations and procedures that are placed or performed solely for cosmetic reasons. These types of treatments might include: teeth whitening, porcelain veneers, dental bonding 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) What deductibles are involved with the policy?

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 plans typically don't require the payment of a deductible.

You need to understand how the deductible is calculated.

If a deductible is involved, there are a few questions you should investigate. Is the deductible calculated just on an individual basis or is there some type of cumulative family deductible (which ends up costing the family slightly less)? Will any portion of a deductible paid late in one policy year apply to the next year's deductible? Does the deductible apply to all types of dental treatments or are some services (such as Preventive dental procedures) exempted?


E) 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, especially 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 typically associated with traditional (indemnity) dental insurance and PPO plans. It often ranges between $750 and $2000 per year but this value will absolutely vary by way of individual plan. 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 dental procedures, like Basic and Major dental 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 paid) will be applied to the calculation of the patient's maximum benefit limitation.

Use the terms of your policy to your advantage.

You may find that the maximum benefits limitation of the dental insurance plan that you have seems to complicate having work done (like placing a series of crowns on front teeth).

If so, don't overlook the possibility of breaking your dental treatment needs into two parts, one of which is initiated exactly at the end of one benefits year and the other a few days later but in the next benefits year. Doing so can maximize your policy benefits, yet provide a means by which your dental work is still started and brought to completion in a relatively normal and convenient time frame.

Dental Plans
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