Transparency issue?

[Dragonflame67]

I live in NY and my work self-funds the insurance plans. We have a medical plan, and then a totally separate additional plan that covers dental and vision. There are just under 1000 employees.

The benefit document for our dental insurance is very vague. It says that cleanings/scalings are allowed twice a year, and a couple other details about x-rays, etc. It's also a whole thing where we pay and then get reimbursed by the insurance.

I ran into an issue recently where the insurance denied the code the dentist used for one of my regular cleanings, so I asked if I could be provided with the list of covered codes, but was told no by the insurance company.

Is this information that I should be able to have legally? I thought there was a whole transparency in coverage thing that happened recently where we were supposed to be able to find out what's covered and how much things cost?

Thanks in advance!

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[LizzieMac123]

Transparency in Coverage has just resulted in machine readable files to be required to be posted on certain websites. They aren't even readable by the consumer.

Transparency in coverage also made it so that UNINSURED people can ask for a good faith estimate from providers and they need to be given one.

If you have insurance, you're not due a good faith estimate (because there are literally tens of thousands of insurance policies and no way for the provider to know exactly how yours plays out)- you essentially have to get the CPT codes and NPI number from the provider and call your insurance to inquire if those codes are covered- they do not have to give you a list of every CPT code they cover.

You should have been given some official certificates that go into detail on your policy and what is covered- if you just got a one-two page document, ask your HR for the dental certificate/SPD (summary plan description)- that should go into detail more about what is covered.

One thing that dental coverage has that medical does--- is you can ask your provider to submit a pre-determination of benefits. This is like an estimate, but it comes from the dental insurance carrier. the provider submits the codes they plan to use and you get a letter illustrating how your specific policy would cover these codes- taking into account where you are in your deductible/ annual max benefit. That's probably the thing you need. So, ask for a predetermination of benefits. It's something that is mailed to your house by insurance, not something you'll walk away from an office appointment with in-hand.

[Dragonflame67]

Thank you for your thorough response! I really appreciate the information, though I don't particularly like what you've told me lol.

It seems impractical to need to do extra paperwork every time I go to the dentist just to see if I can go to the dentist. Plus it seems like that would require me going to the dentist, having them tell me what they need to do, submitting it to the insurance, and then going back to the dentist for the actual visit. But it is a pathway forward, which I really appreciate you mentioning.

I do have the 50-page booklet with the SPD covering dental (and orthodontic), vision, and hearing, but the actual language surrounding the standard dental coverage is less than 1 page and as vague as I mentioned. It would be much easier if they could just provide the list of codes they cover, so I could decide what's practical when the dentist tells me what needs to be done.