What is the alternate Benefit Clause in a dental plan?
Sometimes a clause is included that you weren’t aware existed, and this can affect your claim in a serious way. One such provision commonly found in dental plans is known as the Alternate Benefit Clause, affectionately named “the ABC.” What is the Alternate Benefit Clause?
What is not covered under a dental plan?
A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits may not cover replacing a tooth that was missing before the effective date of coverage. Still seeing words in the insurance paperwork you don’t understand?
What is an optional benefit waiver?
Once a state includes an optional service as part of its state plan, that service must be provided to all individuals eligible under all eligibility pathways that grant access to the traditional benefit package. Waivers offer more flexibility as they permit states to provide optional benefits only to specific groups and to cap enrollment.
What is the ABC clause in a dental plan?
It is a provision in your plan that is intended to provide coverage for the most cost-effective option. It is a financial limitation that allows you to go ahead with the desired treatment but only covers a certain amount. Which Dental Procedures Are Most Likely to Fall Under this Clause? The ABC differs from plan to plan.
What does alternate benefit mean?
An alternate benefit provision in a dental plan contract allows the third-party payer or insurance carrier to determine the benefit based on an alternative procedure that is generally less expensive than the one provided or proposed by the servicing provider.
What is excluded in dental insurance plan?
All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes, dental coverage and medical health insurance may overlap. Read and understand the conditions of your dental insurance plan.
What is porcelain alternate benefit?
What is an alternative benefit? The carrier pays toward a less expensive, but "adequate" service, such as an all-base-metal crown instead of a porcelain/ceramic crown. The patient is typically liable for the amount not covered.
What does the concept of least expensive alternative treatment mean in insurance?
Least Expensive Alternative Treatment (LEAT)- Your plan may have a LEAT clause. That means that if there is more than one way to treat a condition, the plan will pay for only the least expensive treatment.
What are limitations in dental insurance?
Limitations determine how often a particular service is covered and are related to time or frequency (the number of procedures permitted during a specific period). For example, no more than two cleanings in 12 months or one cleaning every six months.
Which of the following is not a common exclusion for a dental expense policy?
All of the following are common exclusions found in dental insurance plans EXCEPT: routine oral examinations.
Can dentist charge more than insurance allowed in California?
(For example: The regular fee for a crown is $1000 but the insurance contracted fee is $800.00 and they pay 50% of that. The dentist then cannot charge more than the contracted fee for allowed procedures.)
What does UCF mean in dental bill?
Frequently, insurance companies state that the reimbursement was reduced because your dentist's fee has exceeded the usual, customary, or reasonable fee "UCF" used by the insurance company.
What does it mean when insurance downgrades?
Insurance companies will elect to pay for the least expensive procedure if there is more than one acceptable option. This is called a downgrade. When the patient chooses a more expensive option, they must pay the difference between the two.
What is an alternate benefit clause?
The Alternate Benefit Clause is a stipulation in many dental plans stating that certain dental procedures must convert to a less expensive treatment. The patient can still receive the more expensive treatment, but is reimbursed for the amount of a procedure that 1) is less expensive and 2) serves the same function.
What is the ABC clause in dental insurance?
One such provision commonly found in dental plans is known as the Alternate Benefit Clause, affectionately named “the ABC.”.
What is a predetermination of benefits?
Most insurance providers require an estimate or “predetermination of benefits” that lists the proposed treatment, the proper codes, the costs, the teeth involved and a panoramic x-ray of the patient’s entire mouth. The insurance provider reviews the estimate and x-ray and determines what procedure is eligible for reimbursement.
What does ABC mean for dental?
The ABC is not meant to dictate your choices, but to limit coverage.
Does ABC apply to dental implants?
The ABC does not apply to excluded services. Even if the dentist sends an estimate stating that implants are the optimal or only solution, they would not be eligible, and you would thereby be responsible for any costs.
Does dental insurance cover everything?
Supplemental dental insurance coverage is an important part of maintaining your health and your smile, but it doesn’t cover everything. If you ever require extensive dental work, beware of the clauses and provisons that almost always go hand in hand with dental coverage.
Do you need to have a metal filling for an ABC?
Tooth-coloured fillings on molar teeth may convert to the equivalent metal. Again, you don’t need to have the metal fillings placed; but you will only be paid their equivalent cost.
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States have the option to provide alternative benefits specifically tailored to meet the needs of certain Medicaid population groups, target residents in certain areas of the state, or provide services through specific delivery systems instead of following the traditional Medicaid benefit plan.
Alternative Benefit Plan Final Rule
A final rule, published on July 15, 2013, entitled, “Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment” (CMS-2334-F) made major changes in the Medicaid Benchmark Requirements..
What is optional LTSS?
Optional LTSS benefits can be provided under the state plan or through waiver programs. Once a state includes an optional service as part of its state plan, that service must be provided to all individuals eligible under all eligibility pathways that grant access to the traditional benefit package.
What is the ACA 111-148?
111-148, as amended) mandates that many preventive services be provided with no cost sharing to individuals enrolled in exchange plans, Medicare, and Medicaid expansions to childless adults, who are often referred to as the new adult group ( HHS 2014 ).
What is non emergency transportation?
Non-emergency transportation to medical care 1. Early and Periodic Screening, Diagnostic, and Treatment services for individuals under age 21 (screening, vision, dental, and hearing services and any medically necessary service listed in the Medicaid statute, including optional services that are not otherwise covered by a state.
What is covered by Medicaid for children?
Children under age 21 are covered under the Early, Periodic, Screening, Diagnostic, and Treatment benefit , which requires states to provide all services described in the Medicaid statute necessary to correct or ameliorate physical or mental conditions found by a screening, regardless of whether that treatment is part of the state’s traditional Medicaid benefit package. This includes treatment for any vision and hearing problems, as well as eyeglasses and hearing aids. In addition, regular preventive dental care and treatment to relieve pain and infections, restore teeth, and maintain dental health, as well as some orthodontia, is covered. States must establish schedules for screening, vision, dental, and hearing services.
What are the mandatory benefits of LTSS?
The only two mandatory LTSS benefits provided to these beneficiaries are nursing facility and home health services. All other LTSS benefits are optional. Optional LTSS benefits include home and community-based services, such as personal care attendants and adult day care, and institutional LTSS, such as intermediate care facilities ...
What is EPSDT for children?
For children, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements limit the extent to which states may apply criteria other than medical necessity to covered benefits.
What is covered by the ADA?
In addition, regular preventive dental care and treatment to relieve pain and infections, restore teeth, and maintain dental health, as well as some orthodontia, is covered.
When the treatment cost is shared by the plan and the enrollees (that’s you!), the cost
When the treatment cost is shared by the plan and the enrollees (that’s you!), the cost of the plan will be much less. Different ways to share costs include deductibles, co-payments, frequency limitations, annual maximums and use of a fee schedule to calculate benefit payments.
Does dental insurance cover pre-existing conditions?
Pre-existing Conditions. A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits may not cover replacing a tooth that was missing before the effective date of coverage.
What is dental discount?
A dental discount program is a savings option, which helps you receive 20%-50% off the full cost of services. A dental discount program requires a monthly or annual membership fee that provides access to participating dentists. Unlike insurance, a discount program won’t include any sort of deductibles, copays, or maximum limits on coverage. Instead, it provides a discount off the retail cost of services through a participating dentist, leaving you responsible for the remaining cost at the time of services.
Is dental insurance expensive?
However, if your oral health care needs are minimal and your options for appropriate care are reasonably priced, you may find that paying out of pocket is a safe and affordable alternative to dental insurance coverage expenses or a discount plan membership.