The Colorado state legislature recently passed legislation (SB-190) proposed by the Colorado Dental Association that prohibits dental plans from holding network dentists to their contracted fees for any dental procedures that are not "covered services," effective for dates of service starting August 9, 2017. Delta Dental of Colorado will comply with this new legislation in a manner that is consistent and easily understood.
Covered services are defined as "dental care services for which reimbursement is available under a covered person's plan,
or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other contractual limitations."
This legislation will impact Delta Dental members (and all other insurance companies) to some degree in the form of higher out-of-pocket costs if they choose a procedure that is not covered by their plan. However,
it should not be significant because most dental procedures required to prevent and treat dental disease remain "covered," meaning they are billable at the contracted rate. Most "non-covered" services, by contrast, tend to be cosmetic and/or optional.
Payment policies that govern the handling of non-covered services do not affect group premiums and/or our administrative-services-only (ASO) rates because there is no reimbursement by either Delta Dental of Colorado or our self-funded group plans. Non-covered services, whether paid at the submitted or contracted fee, remain services for which enrollees must pay the full charge.
The following examples may help illustrate "covered" versus "non-covered" services:
- If tooth whitening is not covered under a given group contract, submitted fees will be honored.
- If a plan covers two cleanings per calendar year, a third cleaning within a calendar year is denied due to a "frequency limitation." Because cleanings are covered by the plan, this third cleaning is still a "covered service" and will be held to the contracted fee for cleanings.
- A posterior composite is often subject to an "alternate benefit," so it will be considered a covered service because DDCO provides a benefit up to the cost of an amalgam. This legislation will not change the processing of such claims, and providers will continue to be held to the fee for the actual service rendered, even if it is an alternative to the allowed procedure.
If you have additional questions about this legislation, please contact your account manager.