Lost a tooth before your dental insurance kicked in?
I hope not, but if that’s the case, You’re now affected by the missing tooth clause.
In this post, I’ll share everything you need to know about it – from why insurance companies include it to how you can appeal denials.
Along with proactive solutions that can help you save money.
Table of Contents
Missing Tooth Clause Definition
A missing tooth clause in dental insurance policies means that any treatment for the teeth lost before the policy start date is not covered by the insurer.
Understanding
Why is a missing tooth considered a pre-existing condition?
In this rule-based world of insurance, any type of negative health condition that existed before the start of your policy coverage is considered pre-existing, and it’s seen as a liability, like any chronic disease.
It can impact the coverage of dental treatments quite significantly.
- Example: If you were planning to get a bridge, implant, or dentures to replace a tooth you lost before and your policy has this clause, you may be out of luck for now because they will invoke this provision, leaving you high and dry to pay the bill for these treatments.
It’s absolutely legal and it’s our responsibility to understand how insurance contracts work, including the harsh parts.
Why do insurance companies have this missing tooth clause?
They use this provision in the contract to reduce claims, i.e., limit their liability for people who only buy insurance for expensive procedures.
If there were only a small percentage of people making such claims, then maybe insurance companies wouldn’t have been so strict, but let’s see some statistics:
35.7% of adults aged 20 to 64 experienced tooth loss.
As per a 2017 study by the National Library of Medicine.
26% of people have 8 or fewer teeth.
17% of people have no teeth.
Poor, uneducated, and smoking adults have a 3x higher risk of losing all their teeth.
A report by the Centers for Disease Control and Prevention shows that it gets worse for the population over 65.
So, the risk is high, and believe me, the impact of this little clause can be significant. It can mean the difference between having a $3,000 dental implant procedure covered and having to pull that money directly from your pocket.
Understanding such limitations can be a game-changer in how you approach medical treatments and insurance policies moving forward.
The Effects of a Missing Tooth Clause
How do insurance companies handle pre-existing conditions?
Some plans simply don’t cover them, while others have a waiting period.
- Delta Dental, one of the most popular dental insurance companies, generally includes a missing tooth clause in their policies.
- Cigna, another big name in the dental insurance world, does as well.
But remember, the terms and conditions vary between plans, even within the same company, in the form of additional riders or premium plans.
How does the missing tooth clause affect the coverage of a bridge prosthesis?
A bridge is a treatment for dental prosthesis that ‘bridges’ the gap by using the surrounding teeth as support where a tooth is missing. So the insurance company may refuse to cover the cost of the bridge, citing the missing tooth clause.
Dental Insurance Options
Is there any dental insurance with no missing tooth clause?
The good news is, yes, there are some!
You can Google “best dental insurance plans” to learn about the top available options.
Some providers recognize that a missing tooth can be a serious issue for many people, and they do offer plans without this clause, meaning they’ll partially cover the cost even if it was missing before your policy started.
But here’s the catch: such plans are costlier since the company is taking on more risk, and for many people, it’s worth the peace of mind.
There may be some dental insurance plans that have some or no waiting period.
This means you can get your dentures as soon as you need them or by waiting for a specific period of time until the coverage starts.
And there’s some tiring news also, i.e., you’ll need to specifically visit the insurance company’s website to read the fine print or confirm via customer care about such clauses, exclusions, waiting periods, etc. because review sites don’t generally go this much in detail.
Example: The one I came across is Guardian Direct; they provide 50% with a 12-month waiting period.
Insurance companies do provide a free look period for some days, so you can cancel the policy without any loss if you find any discrepancy or change your mind within that period.
How does group dental insurance work?
Group dental insurance plans often come without a missing tooth clause; if you’re part of a company that offers group dental insurance, you might already have access to coverage you need.
79% of Americans had dental benefits, the majority of which were employer-sponsored.
According to the NADP 2019 Dental Benefits Report.
So, first check with your company’s HR department – you might already have exactly what you need!
Solutions and Proactive Measures
If you have a missing tooth clause in your insurance policy, what should you do?
First things first, you need to officially confirm that your policy actually has it. And for this, ask questions directly to your insurance provider’s customer service. When it comes to understanding your coverage and saving money, there is no such thing as a silly question.
Stay calm if the result is positive.
Your next step is to get an estimate from your dentist for the tooth replacement procedure. Make sure they include the specifics of the procedures they’ll perform to start the process of predetermination.
What is a dental insurance predetermination, and how can it benefit patients?
It is a process when the dentist sends the treatment plan to the insurance company before starting any procedure, which they review and determine coverage.
Getting a predetermination is worth the wait, as it provides a clear picture of your financial responsibility before any treatment is started.
How can a treatment plan help a patient deal with the missing tooth clause?
Your dentist prepares a document that lists recommended procedures, their costs, and a completion timeline. This plan explains the treatment costs and coverage options, which can be later used to support your appeal for a denied claim.
And lastly, consider leveraging dental insurance verification services, as they will help you understand your policy, coverage, and limitations in detail, which can be a great ally in dealing with such situations.
What is a waiting period in a dental insurance policy?
A waiting period is a specific period of time when the plan won’t cover certain treatments. You need to wait for it to pass before receiving coverage for specific treatments, including costly procedures like tooth replacement.
How does this relate to the missing tooth clause?
If your dental insurance has this clause and a waiting period for major dental procedures, you might assume that your policy would cover the cost of replacing a missing tooth after the waiting period. This is not usually the case.
The waiting period and missing tooth clause are separate. The waiting period applies to lost teeth or required procedures after the policy starts. The missing tooth clause applies to teeth that were missing before the policy started.
Is there any exception to this missing tooth clause?
Yes, there are circumstances when this clause might not apply. Suppose you had an existing bridge, implant, partial, or denture already in place, and now you find yourself in need of replacing that old denture that’s been there for over a decade.
In such a situation, this clause should not prevent you from receiving coverage because, technically, the tooth in question was replaced long before the start of your current insurance plan.
You’ll need to provide a lot of information, like the tooth’s original placement date, the diagnosis behind its replacement, and the anticipated outcome or prognosis.
You’ll also need to back up your claim with supportive documentation, which typically includes x-rays, intraoral photos, detailed narratives, etc., in order to ensure that your insurance provider grants this exception.
Can an insurance company waive the missing tooth clause under any circumstances?
Potentially yes. Each case is unique, and it never hurts to try when you have a strong case and can provide convincing evidence.
Medicaid and Dental Insurance
Can Medicaid act as dental insurance without this clause?
Medicaid varies by state. However, states have different rules for dental coverage. Generally, Medicaid focuses on providing essential services, and its coverage for dental work can be limited.
What are the eligibility criteria for Medicaid?
It also varies by state and typically considers several factors like income, family size, disability status, and other criteria. Connect with your state’s Medicaid program directly to get accurate details.
Navigating and Overcoming the Missing Tooth Clause
How can an appeal and appropriate documentation help when an insurance claim is denied?
You can appeal the decision. An appeal needs to be filed with as much supporting documentation and evidence as you can, like X-rays, photos, detailed narratives, or a detailed letter from your dentist explaining why the procedure is urgent for you right now, which can sometimes make a difference.
Visit how to win dental insurance appeals to learn more.
Note: The outcome of an appeal is not guaranteed, but if you do not try, you’ll never know. So, don’t give up. Gather your evidence and make your case. It’s definitely worth a shot!
What other financial options are available if a dental insurance plan doesn’t cover tooth restoration?
Other financial options may include payment plans, discounts for upfront payments, dental discount plans, or even third-party financing companies.
Dental Discount Plans vs Dental Insurance
What is a dental discount plan?
These plans don’t pay for dental costs directly. Instead, they offer discounted prices on dental services after you pay the membership fee to avail yourself of the services at a lower price.
These plans don’t have a missing tooth clause. You can save money on replacing a lost tooth even if you were not a member before. These plans also do not have any waiting periods for major procedures.
Comparison of in-network and out-of-network dentist costs under different plans
In-network dentists offer discounted services to patients within a specific insurance or discount plan. On the other hand, out-of-network dentists haven’t agreed to reduced rates.
Therefore, using an out-of-network dentist may cost more than using an in-network dentist.
You need to consider the following distinctions to ensure that you are choosing the best dental insurance or a discount plan for yourself.
- Is your favorite dentist in-network or out-of-network?
- How do costs compare under different plans?
What are other limitations to consider in a dental plan?
Each policy is a unique blend of coverage, riders, exclusions, in- and out-of-network benefits, deductibles, and costs. It’s important to understand what it actually covers. Most plans break down their coverage into three categories: preventive, basic, and major.
Preventive care includes cleanings, exams, and x-rays, while basic procedures cover things like fillings and extractions, and major procedures include costlier treatments like crowns, bridges, and dentures.
And not all plans are created equal. Some might cover orthodontic work or implants, while others don’t. Some might cover 100% of preventive care but only 50% of major procedures. You must carefully study what’s covered and what percentage of the costs you’ll be responsible for.
Your policy may have additional exclusions and limitations.
- Example: Some insurance companies won’t cover cosmetic procedures like teeth whitening or veneers. Others might limit the frequency of payment for certain procedures.
These are the details you’ll want to be clear on. Costs are another major factor. This includes not just your monthly premium but also deductibles, co-pays, and annual maximums. Make sure you understand all these costs and that they fit within your budget.
The Relationship Between Dental Practices and the Missing Tooth Clause
How can dentists benefit from a better understanding of the missing tooth clause?
A knowledgeable dentist can guide patients on anticipating potential out-of-pocket expenses, treatment options, and avoid surprises.
On the other hand, if the patient gets an expensive treatment without predicting a coverage denial, it could put them in a difficult financial situation and lead to a loss of revenue for the dentist or a struggle to collect payment.
As a result, dentists must effectively deal with such challenges, and this may involve educating the patient, verifying insurance benefits before proceeding, exploring alternate treatment or payment plans, and appealing insurance decisions when necessary.
Over to you
I’d like to hear your experiences:
What type of difficulties did you face? Or How did you overcome such a situation?
Either way, let me know by leaving a comment below right now.