Dental insurance restrictions: Pre-existing conditions, wait periods.

Also: Excluded services, frequency of service limitations, deductibles, annual maximum benefits. | Possible work arounds for policy restrictions.

Does dental insurance cover pre-existing conditions?

It's common to find that your dental coverage has some type of restrictions or exclusions attached to it. This would be especially true for insurance policies. (Limitations are usually less of an issue with dental discount plans.)

What type of limitations are common?

Why do policy restrictions exist?

In the case of dental insurance, it's easy enough to understand why some 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 types of limits listed above are incorporated into a plan as a way of helping to control the company's overall expenditures, so it will remain in business to provide benefits for other policy holders too.

Do dental insurance policies usually cover pre-existing conditions?

Some do. Others, despite what they may suggest, have restrictions in them that in effect prevent your policy from serving your immediate dental needs. Here are some examples of the range of terms and conditions you may find.

a) Policies where previously existing conditions are covered.

Dental conditions are frequently slow to develop.

Many types of dental problems progress relatively slowly over the years. For example, it's not uncommon that during a routine checkup a dentist will inform their patient that an area of decay or an deteriorating filling has finally advanced to a point where it now requires repair.

"Previously existing" doesn't necessarily equate with the term "pre-existing."

In such cases, while the set of conditions that lead up to the person's current problems did exist beforehand (for months, possibly even years), the dental needs they've created (a filling, a crown) aren't defined as pre-existing conditions and will be covered.

If so, if you have a new insurance plan and at your first exam your dentist discovers that you have existing cavities, teeth that need root canal treatment or to be extracted, ongoing gum disease, or even large fillings that you had always planned to replace with dental crowns, they'll have the same coverage as if they had been discovered after your policy had been in force for a long time.

b) Policies where pre-existing conditions are covered, although not immediately.

If an insurance provider is interested in imposing some type of pre-existing conditions restriction, they'll frequently do it by way of including a "waiting period" clause in their policy.

For example, with the above list of procedures the patient might find that their plan provides coverage for fillings or extractions immediately. But before benefits for more involved dental needs are provided (like crown placement or gum surgery) they will need to wait a certain number of months (6 months to a year is common).

Wait period variations.
  • Some plans may be so restrictive that only diagnostic and preventive services (exams, cleanings, x-rays, etc...) are covered during the wait period.
  • As a twist, a policy may waive its waiting period requirement if the insured can document that they were previously covered by another dental policy.
Implementing a waiting period helps to weed out pre-existing problems.

When a wait-period clause exists in a policy it provides a way for the insurance company to avoid many of the claims for previously existing conditions that they otherwise would have had.

For example, if a person who at the time of their enrollment already has a painful broken tooth (a pre-existing condition), due to their policy's wait-period stipulation they will be placed in a position where they must foot the bill for having it repaired on their own.

c) Other types of pre-existing condition exclusions.

Some insurance plans contain clauses that detail types of pre-existing conditions that specifically are not covered. Examples of these types of exclusions include:

  • No benefits for the completion of dental work that was started before the person first became covered by their plan. (Some policies have exceptions for the continuation of orthodontic work.)
  • No coverage for replacing crowns, bridges or dentures that are less than a stated number of years old (often 5 or 7 years).
  • The exclusion of coverage for dental appliances (bridges, dentures, implants) used to replace (just those) teeth that were extracted before the person was covered by their current plan.

Does your dental plan cover pre-existing conditions?

The only way to know for sure is to check or ask. If you don't feel qualified in reading through your policy or the promotional materials that came with it, your employer or else the company that sold you your policy should be able to provide you with an answer. So should the staff at your dentist's front desk, so just ask.

What determines if a plan will or won't cover pre-existing conditions?

The two primary determinants are policy cost and governing regulations.

  • Plans that contain previously existing condition exclusions are likely to be lower in cost because fewer claims are ultimately paid out. This factor may make them more competitive in the marketplace.
  • In some cases, state or federal regulations may apply that dictate the types of terms and conditions that policies sold under their jurisdiction must include.

More details about dental plan "wait" periods.

What is a "wait" period?
  • A policy waiting period is a time frame during which certain types of procedures are not covered, or else not covered as fully as they will be after an initial time period has elapsed.
  • Common time frames for waiting periods are 6 or 12 months.

As an example:

  • You may find that during the first year of your new plan's term only diagnostic and preventive dental services are covered (exams, cleanings, x-rays).
  • More extensive dental work, such as the placement of crowns, root canal treatment or possibly even just basic fillings are not.
  • Then, after the term of the waiting period has lapsed, the plan initiates benefits for the previously excluded services too.

A wait period is the insurer's way to limit their financial exposure.

The classic explanation for a company's need for a wait clause is simply this.

A person with immediate dental needs might ...

  • Enroll in a plan.
  • Have extensive work performed during their first few months of coverage.
  • Drop the policy once their treatment has been completed.

With this scenario, the dollar amount of premiums paid likely will not come close to covering the cost the the member's (now ex-member's) claims. And while a company doesn't necessarily expect to make a profit on every single member, if a large number were to take advantage of this loophole it would have difficulty staying in business.

Possible work arounds for waiting periods.

Depending upon your situation, a plan's wait period clause may make it unsuitable, or at the very least unaccommodating to your current needs. However, you may have some options in finding a way past this obstacle.

► If you've had previous dental coverage ...

Some policies state that if the insured had dental coverage within the last 60 days prior to enrolling (you'll need to provide documentation), the waiting period may be waived.

► If you're a member of a group with new insurance ...

Wait-period restrictions may not apply if you're part of a group that has just joined a program (such as your employer has enrolled your company in a new dental plan). However, future hires (new employees to the company) frequently will have one imposed.

► Possibly some portion of your treatment can be delayed ...

Some types of dental conditions may not require immediate attention. This might include areas of arrested decay, deteriorated but seemingly stable dental crowns or fillings, ill-fitting dentures, etc... If so:

  • Their resolution may be able to be postponed until after your wait period has expired and full benefits for your needed procedures become available.
  • It may be possible to address more active concerns by temporizing them (likely at your own expense). Your permanent dental work can then be placed at a later date.

Under no circumstances should you make these types of treatment decisions on your own. Instead, take advantage of the diagnostic services that your policy currently makes available to you (exam, x-rays) and then discuss with your dentist which of your dental needs might be reasonably postponed.

Restrictions involving the types of procedures covered.

You'll need to confirm that the policy that you're considering provides benefits for the types of dental services 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 commonly, 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.

Limitations governing how frequently 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. Full and partial dentures may only qualify once every 7 years.

Policy deductibles.

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?

Maximum annual benefits.

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 ($1500 is common) 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, here are some possible solutions:

  • Check to see if your policy allows that (some or all) of your previous year's unused annual maximum can be rolled over into your next year's. If this option is available, it alone may solve your dilemma.
  • As another alternative, ask your dentist if your treatment plan can be broken up 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.

    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. (Your dentist will need to check to see what's allowed but claims paid are typically based on the date on which the procedure was initiated, not completed.)



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