Is this gaming the insurance system? If so, will it work?

April 28, 2008 11:35 AM

Dental-insurance-filter: I'm a grad student who has the option of paying for better insurance starting next fall. If I opt for full coverage, will my insurance refuse to pay for procedures already suggested on my chart?

As you can tell, I'm new to the world of medical insurance.

I just had my first consultation with a periodontist this afternoon. She recommended one procedure for $200 that I'd definitely need to do, and two more that were optional (they'd make my teeth look better but also help to keep them healthy) at $1000 and $800. Right now, I'm on the lowest-tier insurance plan my school offers, so I'm paying for all my dental bills out of pocket. I can't schedule anything until I get back to school in September anyway, so no matter what I'm waiting until then.

If I opt for a better insurance plan starting in the fall semester, should I expect them to cover any or all of these procedures? If it matters, I believe the plan offered is from Delta, but I'm mainly concerned that these are "pre-existing conditions" — on the other hand, I'm not sure if that applies to dental insurance like [I think] it does to general health insurance.

Is there a way to find out with certainty whether they'll cover it before I sign up for the plan? Or will asking about it ensure that they won't pay?

posted by electric_counterpoint to health (3 comments total)

Just find out the specific plan your school offers, and research it online. It will definitely say whether or not they'll pay for pre-existiting conditions. FWIW, mine* won't pay for work that's already begun, like crown preparation. Of course, that's one of the things I already had started.

*not Delta
posted by oneirodynia at 1:30 PM on April 28

You should be able to ask your periodontist (or their billing staff) as well. You will need to be able to name the specific plan(s) you're considering.
posted by oneirodynia at 1:33 PM on April 28

I played a large role in creating the insurance policy that covers grad students at my University. A major selling point of the plan we created was that it must not exclude coverage for pre-existing conditions for enrollees. While this kind of exclusion is commonplace for many free-market plans, it's really frowned upon in the college health world, since it encourages students not to enroll, which debases the plan and increases the risk of public health problems on campus.

The elimination of such exclusions also happens to be a specific requirement of the American College Health Association's Student Insurance Guidelines.

If the plan you'll be on is a good plan, it's probably ACHA compliant, and will not have this kind of exclusion. It's likely that the University has someone on staff who's job it is to answer just this kind of question. So you should call your University's Health Services (or whoever administers the plan) and ask directly. They probably even have this information online in the plan benefits documentation, so you might start with a Google search.

I can't comment on whether your scheme will work should the exclusion be in place, but it's reasonably likely it will be a moot point.
posted by dseaton at 1:39 PM on April 28