State Laws for Noncovered Services
Dental clinics in insurance networks must have reduced prices for some of their procedures due to their contract with the insurer (DeWood 2016). They may have to apply them to noncovered services, depending on their state and insurance company (DeWood 2016). Consequently, dentists could choose to “either not make certain treatments available due to cost constraints or not take insurance that a majority of patients have” (Saxe 2013). They could negotiate these fees with the insurance companies, but the increased fees may not be substantial enough to increase overall revenue (Hatch 2017). Fortunately, they can offer procedures at the full fee “[for] any procedures not listed on the [PPO] fee schedule list…” (Johnson 2018). Though, in most states, their laws do not allow insurance companies to reduce prices for noncovered services (DeWood 2016).
These state laws apply to noncovered services, but not services affected by provisions in their contract. States, such as California, Arkansas, and Connecticut, have those laws, benefiting dental practices, who could offer noncovered procedures at their full price (DeWood 2016). Though, these laws also mean that patients would not pay reduced fees for these noncovered procedures (“Non-covered Procedures Legislation by State”). Though, the laws distinguish noncovered services from services limited by provisions in their contract. For instance, in California, the law does not apply to covered procedures and services that have “‘contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, or alternative benefit payments…’” (“How to bill for noncovered procedures” 2016). Similarly, Arkansas’ law also excludes covered services that are “reimbursable subject to a deductible, waiting period, frequency limitation, annual or lifetime maximum, or other contractual limitation” from their noncovered services classification (Hickerson et al. 2011). Meaning, dentists still have reduced fees for covered procedures with contractual limitations in accordance with their contract with the insurance company (“How to bill for noncovered procedures” 2016).
Some of these state laws may not apply to self-funded plans. This type of dental plan can come from “large employers, government employers, unions and businesses that have operations in more than one state” and “are typically administered by commercial dental plans, but they are not commercial coverages purchased in the market” (“How to bill for noncovered procedures” 2016). Self-funded health plans are not regulated by state law, but rather by federal law (“How to bill for noncovered procedures” 2016). Consequently, depending on their state, such as California, dental clinics contracted with self-funded dental plans must agree to any reduced fees for their noncovered procedures (“How to bill for noncovered procedures” 2016).
Dental practices should be aware of any noncovered services law in their state because they could charge full price for these procedures in order to earn more revenue. However, some states may not have such laws and these laws may not apply to every dental plan.