KDA Today

KDA Today

For Immediate Release

Date: Oct 17th, 2013
Contact: Dr. William J. Moorhead
Phone: 800-292-1855
Email: info@kyda.org

Kentucky Department of Insurance, HB 497 and Non-covered Services

In 2012, the General Assembly passed HB 497 regarding non-covered services. The Kentucky Department of Insurance reviews limited health benefit plans under KRS 304.17C and they are tasked with enforcing the provisions of KRS 304.17C from HB 497. In the 2013 Regular Session, SB 70 which provided a definition of non-covered services failed. Upon passage of HB 497 in 2012, KDA representatives met with the Department of Insurance regarding the implementation of HB 497. The Department of Insurance said that they would enforce the law on a case-by-case basis and they have remained consistent with their enforcement of KRS 304.17C following SB 70 not passing. This means that it is enforced on a complaint-by-complaint basis.

When the Department of Insurance reviews these complaints they look at the definition of covered services in the provider contract and also look to determine if the requirements of the law are effective immediately, upon renewal or at renegotiation of the contract.

As you review your patient’s EOBs, below are some examples of non-covered services for which you may want to consider filing a complaint to the Kentucky Department of Insurance: (These examples have been given under each item for explanation and are not exhaustive in the number of non-covered services that may apply.)

1. Frequency limitations

If a patient requires more than two exams and prophylaxis in a given year and consents to that treatment, the additional exam and prophylaxis is deemed a non-covered service and is not subject to the insurance carrier’s set fees.

If a tooth is restored and the patient breaks the tooth or is non-compliant in his/her oral hygiene and decay results necessitating a new restoration being placed within the time limitation set forth by the insurance carrier, that is deemed a non-covered service and is the responsibility of the patient to pay. (Some PPO contracts are now stating it is the dentist’s expense to replace the restoration at no charge if placed within the last two years.)

2. Alternative benefit payments

If you recommend a composite restoration on a posterior tooth and the patient consents even though his/her benefit does not cover posterior composites and the insurance company pays the corresponding amalgam fee as final, you are allowed to bill the patient for your posterior composite restoration fee.

If you recommend a fixed bridge and the insurance carrier substitutes a removable partial for payment, you are allowed to bill the patient for the fixed bridge.

3. Waiting periods

If a patient has a waiting period which has not been met, you are not obligated to use the insurance carrier’s set fee for the procedure subject to the waiting period. In other words, if a crown is recommended, but the patient has a one-year waiting period, you are not required to use the carrier’s fee for the crown, since it is a non-covered service.

4. Annual and lifetime maximums

When the patient’s annual maximum has been exceeded you are not bound by the insurance carrier’s set fees for additional services that the patient may receive within that contract year.

Similarly, the same rational applies to plans that set a lifetime maximum.

The KDA is providing you with this information to remind you that if you have any concerns with a provider contract, we recommend that you file a complaint with the Kentucky Department of Insurance. Their contact information is:          

Commonwealth of Kentucky, Department of Insurance, P.O. Box 517, Frankfort, KY 40602

If you have any questions, please feel free to contact Michael R. Porter, KDA Executive Director at mike@kyda.org or (502) 489-9121. We would also appreciate you sending a duplicate copy of your complaints to the KDA, as well. (Send the duplicates to mike@kyda.org or KDA, 1920 Nelson Miller Parkway, Louisville, KY 40223-2164.)

By working together, we can all benefit our profession for years to come. Thank you for your assistance.  

 

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