141 Dental Studio

“Sorry, that’s not covered.” (Clauses, Exclusions and Limitations)

As I stated before everything is NOT covered 100% by your dental insurance plan. If a tooth needs to be refilled or if you need or want a new denture then there may be a delay in coverage or no coverage. So let’s highlight some of these clauses, exclusions and limitations.

Limitations

X-rays are a necessary tool in diagnosing dental problems. Depending on how long it’s been since you’ve been to the dentist or if the dentist sees a lot of questionable things in the mouth will determine the number and frequency of x-rays you will have to take. Insurance will pay for a full set of 18 x-rays every 5 years. This can especially get a little tricky if you’ve already had a full set of x-rays done and you decide to go to a new dentist. You can request the x-rays from the old dentist, but if the x-rays cannot be properly read then you may need new x-rays taken.

Also, most of the time two cleanings per year is sufficient. Some plans will pay for 2 (I’ve seen some pay for 3) and their must be a certain length of time between those cleanings. Some people (believe it or not) like to have their teeth cleaned more frequently. Those “extra” cleanings will not be covered and will be an out of pocket expense.

Another issue may be with tooth-colored fillings. At one time tooth-colored fillings were reserved for front teeth and you had to get a metal filling for a back tooth. The tooth-colored fillings were not as strong and the metal ones lasted longer, though they don’t look that good. Tooth-colored fillings have improved and are stronger and can be safely used in back teeth. Even still, some insurance plans (especially those backed by government funds or unions) will only pay for a metal filling. You may have the option to get the tooth-colored filling and pay the difference or just pay the full cost out of pocket.

Replacements

A lot of patients have fillings, crowns and dentures (dentures include both full and partial dentures). But let’s face it…things happen! Dentures break, get lost, don’t fit because of changes in the mouth (or not wearing it like the patient is supposed to), fillings and crowns break, bridges fail and fillings come out. If you’ve recently had the denture, crown or filling and it has to be redone, that may be an out of pocket cost for you. Most insurance plans will only cover a new one after 60 months…yes, 5 YEARS!! Theoretically, fillings, crowns, bridges and dentures should last at least this long or longer; however there is no guarantee. So to minimize any additional cost make sure you really take care of your restoration.

Missing Tooth Clause

Another trick with dental insurance is that you may have this little thing called the “missing tooth clause” (pre-existing condition). This means if the tooth was missing before your coverage began then the treatment to replace that tooth will not be covered unless other teeth will be removed and replaced. So, if you have that one tooth that has been missing since you were 8 and you are now 32 and want to have it replaced, you may have to reach in your wallet.

Exclusions

In addition to the “normal” dental procedures, you also have “cosmetic procedures” (tooth-colored filling for back teeth, veneers, whitening, some crowns or implants) which are not covered. They are not covered because the insurance company feels as though there are other procedures that can be less costly for them or the procedure may not be “necessary”. This can mean removable partial dentures instead of bridges, metal fillings instead of tooth-colored fillings for back teeth or a bridge instead of an implant. Speaking of implants, more and more patients are opting for implants and dentist and dental organizations are lobbying for insurance companies to recognize that implants are necessary and a better option for some patients. If your plan covers implants they may only cover a portion, but more than likely not cover it at all. Even if they do cover the implants there may be a limit as to how many you can get.

Whew! That’s a lot to remember and consider. It is EXTREMELY important that you as the consumer understand your dental benefits, and medical benefits for that matter. What should be straight-foward may be a more confusing than you think. But even if a procedure is not covered for whatever reason you have to remember that your dental team has been trained for years and continue to get training to recognize dental problems and come up with the best solutions to treat them. Dentists have your best interest at heart and are passionate about making sure you have optimal oral health. Even if your plan does not cover a procedure does not mean you don’t need it. People have become very sick and even died from dental infections that could have been prevented or treated properly. You MUST make your overall health a priority-and that includes your oral health!

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141 E 55th St #2B, New York, NY 10022 212.262.2952