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Enhanced Dental Benefits Coverage For Patients With Certain Medical Conditions

More dental plans are looking at emerging science regarding connections between oral and overall health. This has triggered some dental plans to enhance their dental benefit plan design options to support improvement in overall health.  

In addition to some dental plans not counting preventive and diagnostic benefits towards the plan’s annual maximum, here is a look at examples of what some plans are doing to help patients with medical conditions improve their dental health by offering additional benefits.

The Cigna Dental Oral Health Integration Program claims to be the first to offer additional coverages based on a patient’s medical condition. For example, Cigna will cover 4 scaling and root planings and perio maintenance procedures for pregnant women and patients with heart disease, stroke, diabetes, kidney disease, organ transplants and head and neck cancer radiation. It will also provide an additional cleaning and evaluation for pregnant women. More information on Cigna’s program can be found at  https://www.youtube.com/watch?v=zrqIztv71I8  

Aetna’s Dental Medical Integration program (DMI) includes enhanced dental benefits covered at 100%.  No deductible or paperwork is needed and the extra services do not count toward the member’s calendar-year maximum. This link will take you to more information  https://www.aetna.com/insurance-producer/dental-plans-programs/dental-medical-integration-program.html and this link will take you to a video on Aetna’s program https://www.aetna.com/insurance-producer/dental-plans-programs/dental-medical-integration-video.html 

HOW is the umbrella brand name of Northeast Delta Dental’s oral health outreach and engagement programs for employees, individual subscribers, and family members. HOW builds on the concept that benefit designs, like treatment plans, are most effective when they are personalized. The key is individualized risk assessment linked to evidence-based benefits and care. To be eligible for enhanced benefits, the network dentist must submit a PreViser Oral Health Information Suite (OHIS) risk assessment that indicates moderate to very high risk for caries and/or periodontal disease. Patients with HOW evidence-based plan designs are eligible for enhanced benefits based on their clinical risk assessment including:

  • Up to four prophy or periodontal maintenance visits per year (D1110, D1120, D4910)
  • Up to four fluoride varnish treatments per year (D1206) without age restriction
  • Sealants for adult and deciduous molars (D1351) without age restriction
  • Oral hygiene instruction (D1330), nutrition counseling (D1310) or tobacco cessation (D1320)
  • Caries susceptibility testing (D0425)

For more information on this Delta program, please visit www.healththroughoralwellness.com/Home

In 2012, the ADA dental claim form was revised to include the submission of ICD codes. We are aware that at least one state Medicaid plan (Nevada) is now requesting ICD codes for certain procedures. 

For more information on dental benefits, please visit  https://success.ada.org/en/practice/dental-benefits/dental-benefit-basics/benefit-plan-designs.

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