Limitations on Covered Dental Services
The following services or supplies shall be limited as provided in the following treatment rules:
- Orthodontic Treatment Rule. Orthodontic treatment is covered when the course of treatment is performed on a covered child and the treatment begins prior to the child attaining age 20. The Plan will not cover the charges for an orthodontic procedure if an active appliance for that procedure was installed before the patient became covered by this Plan unless the prior coverage was in active treatment in a local Port-sponsored Dental Plan immediately prior to coverage beginning in
this Plan (see the Orthodontic Replacement Rule below). The Plan does not cover the following orthodontic services or supplies:
- Replacement of broken appliances;
- Re-treatment of orthodontic cases;
- Changes in treatment necessitated by an accident;
- Maxillofacial surgery;
- Myofunctional therapy;
- Treatment of cleft palate;
- Treatment of micrognathia;
- Treatment of macroglossia;
- Lingually-placed direct bonded appliances and arched wires (i.e., “invisible braces”); or
- Removable acrylic aligners (i.e., “invisible aligners”).
- Replacement Rule. Crowns, inlays, onlays and veneers, dentures, removable partial dentures, fixed partial dentures (bridges), and other prosthetic services are subject to the Plan’s Replacement Rule. Certain replacements of, or additions to, existing crowns, inlays, onlays and veneers, dentures, or bridges will be covered only if the Claims Administrator receives proof that:
- While covered by the Plan, you had a tooth (or teeth) extracted after the existing denture or bridge was installed. As a result, you need to replace or add teeth to your denture or bridge.
- The present crown, inlays, onlays and veneers, dentures, removable partial dentures, fixed partial dentures (bridges), and other prosthetic service was installed at least 5 years before its replacement and it cannot be made serviceable.
- You had a tooth (or teeth) extracted while you were covered by the Plan. Your present denture is an immediate temporary one that replaces the tooth (or teeth). A permanent denture is needed, and the temporary denture cannot be used as a permanent denture. Replacement must occur within 12 months from the date that the temporary denture was installed.
- Orthodontic Replacement Rule. The Plan will not cover the charges for an orthodontic procedure if an active appliance for that procedure was installed before the patient became covered by this Plan unless the prior coverage was in active treatment in a local Port-sponsored Dental Plan immediately prior to coverage beginning in this Plan and that coverage began prior to the child having attained this Plan’s limiting age for the commencement of a covered orthodontic treatment plan. This Plan’s coverage will be provided prorata for the remainder of the period of orthodontia as
if it had been the sole coverage since the beginning of the orthodontic treatment but the Plan’s liability shall be limited to payment for the remaining treatment in the orthodontic treatment plan.
- Tooth Missing but not Replaced Rule. The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges) and other prosthetic services will be covered if:
- The dentures, bridges or other prosthetic services are needed to replace one or more natural teeth that were removed while you were covered by the Plan (coverage in a prior local Port-sponsored Dental Plan immediately prior to coverage in this Plan will be considered coverage in this Plan for the application of this rule); and
- The tooth that was removed was not an abutment to a removable or fixed partial denture installed during the prior 5 years. The extraction of a third molar does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.
- Alternate Treatment (or Substitution) Rule. The Plan covers the closed list of procedures that are provided in the list of covered dental services. The patient and the dental provider shall determine the course of treatment that is acceptable. When there are several ways in which to treat a dental problem, all of which would produce an acceptable result, the Claims Administrator will limit the Plan’s coverage to the cost of the least expensive service or supply that would be acceptable. If a procedure is selected that is not included in the Plan’s list of covered dental services, the Claims Administrator will select the procedure which is most like the procedure that actually was performed as the basis for reimbursement. Any additional cost for the service that is actually performed will be the Member’s responsibility. Such acceptable service or supply must meet the following conditions:
- It must customarily be used nationwide for the treatment;
- It must be deemed by the dental profession to be appropriate for treatment of the condition; and
- It must conform with broadly-accepted standards of dental practice, taking into account the patient’s oral condition.
- Rule for Coverage for Dental Work Begun Before the Patient Is Covered by this Plan. This Plan does not cover work that began before the patient became covered in this Plan. Accordingly, the following work will not be covered:
- An appliance, or the modifcation of an appliance, if an impression for it was made before the patient became covered by this Plan;
- A crown, bridge or cast or processed restoration, if a tooth was prepared for it before the patient became covered by this Plan; or
- Root canal therapy, if the pulp chamber for it was opened before the patient became covered by this Plan.
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Rule for Coverage for Dental Work Completed After Termination of Coverage. If dental coverage terminates while the patient is undergoing treatment, the Plan will not cover treatment that is given after coverage ends. The exception to this rule will occur if one of the following procedures was ordered while you were covered under the Plan and the service was completed or the supply installed within 30 days of the termination of the patient’s coverage.
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The procedures on which coverage may continue follow:
- Inlays;
- Onlays;
- Crowns;
- Removable bridges;
- Cast or processed restorations;
- Dentures;
- Fixed partial dentures (bridges); and
- Root canals.
- The meaning of "ordered" as applied in this rule is:
- For a denture: the impressions from which the denture will be made were taken.
- For a root canal: the pulp chamber was opened.
- For any other item: the teeth that will serve as retainers or supports, or the teeth that are being restored:
- Must have been fully prepared to receive the item; and
- Impressions from which the item will be prepared have been taken.
NOTE
If you have additional questions about a service, health care product or expense that may not be covered, call the Plan’s Claims Administrator, Aetna, at the toll-free Member Services number shown on the MILA Resources chart in the Administrative Information section of this SPD.
