2024
Does non-covered services apply to services that are covered only for a particular age group?
In the case of a service that is“ age defined,” or only covered up to a certain age, dentists should not be held to the insurance carrier’ s allowance for patients outside of that age group. For example, fluoride treatments may only be covered until a patient reaches age 14, but not after age 14. If a fluoride treatment is done on an adult, the service would be considered not covered under the terms of the patient’ s contract, and therefore the dentist should not be held to the contract allowance.
How does non-covered services apply to cosmetic services, which are routinely excluded from dental insurance contracts?
Cosmetic services are not specifically addressed in Act 186, however under usual circumstances, services provided exclusively for cosmetic purposes are not subject to insurance company allowances.
It is advisable when performing cosmetic services that the dentist utilize a well-crafted financial responsibility form.
Are Medicare Advantage plans impacted by non-covered services limitations? What about selffunded groups?
Medicare Advantage plans are subject to the provisions of Act 186.
Self-funded plans are, by definition, not insurance contracts. Act 186 does not apply and dentists are not obligated to the group’ s allowance for non-covered services.
Please note, there is unfortunately no guarantee that an insurance carrier will agree with PDA’ s interpretation of particular circumstances that are not addressed in Act 186.
Questions concerning non-covered services can be directed to PDA’ s Government Relations staff at( 800) 223-0016.
2024