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