LA HAP Bulletin for 5/20/19
Changes to dental coverage policy for non-Guardian clients
Please read this bulletin carefully. If you have questions about the upcoming changes, join LA HAP staff for a brief call on Thursday, May 23 rd at 1 pm (Dial: 1-888-398-2342; PIN: 5018903#)
LA HAP and HIP are attempting to define a dental coverage policy that is as uniform as possible across all coverage types. Accordingly, several changes will go into effect on July 1st, 2019 which affect all clients receiving HIP assistance with any dental plan other than the LA HAP/Guardian dental plan. Most importantly, HIP will no longer be placed in the position of having to make determinations of medical necessity related to any proposed dental care.
Summary of changes to current policy effective July 1 st 2019:
Costs incurred when a client is in the insurer-imposed waiting period are not covered.
· The LA HAP Guardian Plan has no waiting period.
· Most Medicare and employer-sponsored dental plans also do not have a waiting period; however, members should verify this information in their Summary of Benefits.
Balance-billed charges for seeing out-of-network providers are not covered.
· Clients still have the option to see any dental provider they wish and HIP will pay any deductibles, co-pays and coinsurance on their behalf. Clients must assume responsibility for any additional charges that might apply.
· This is true for both LA HAP/Guardian members AND non-members. Not all dentists choose to balance-bill their patients but many do, and LA HAP/HIP have no authority to regulate this practice.
Services which are not on an insurer’s Schedule of Benefits are not covered.
· In many cases, an insurance plan contains an “Alternate Benefit Clause” wherein a major service is not covered but a less expensive option (an “alternate benefit”) is. In these situations, clients can opt for the less expensive covered service, or–
· The dentist may perform their preferred non-covered service, and the insurer will reimburse them as if they had performed the less expensive covered service. The client may still be billed by the dentist for the difference between what the service actually cost and what the insurance company reimbursed, but at least they would not be liable for 100% of the cost of the non-covered service.
LA HAP/HIP will CONTINUE to cover costs associated with a covered service that is:
· Above the annual dollar maximum set by the insurer (up to an overall max of $5,000 per year)
· Above the annual service limit set by the insurer (up to an overall max of $5,000 per year)
HIP will only reimburse network providers according to the fee schedule of the client’s primary insurer. For example, if a dentist bills $700 for a service and the insurer’s negotiated in-network reimbursement rate for that service is $500, HIP will reimburse the provider $500. If clients visit an out-of-network provider, balance-billed charges may apply.
In early June, letters explaining these changes will be sent to:
· All clients currently receiving HIP assistance with a non-Guardian dental insurance plan
· All dentists with a recent (since January, 2018) history of billing HIP
When these changes go into effect, LA HAP will post an updated version of our Policy and Procedures Manual online so you may reference it as official policy.