Interpretation of 'Covered Service' in New Laws about Dental Plans
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Guidance on how Nebraska statutes prohibiting plans from dictating prices for non-covered dental services should be interpreted, and which definitions of 'covered service' dental plans may use in provider contracts; applies to insurance carriers and prepaid dental plans in Nebraska.
No material clinical or coverage changes in this revision.
Permitted Interpretations & Application
Allowed interpretations and application
Permitted interpretations and an applied example:
ANY of the following
- 'Covered service' is any service for which the insurer actually paid part of the dental provider's bill; 'noncovered service' is any service for which the insurer pays no money to the dental provider.
ANY of the following
- 'Covered service' is any service the contract provides coverage for, regardless of whether payment is made in a given circumstance (for example, when payment is prevented by annual maximums); 'noncovered service' is any service the contract does not provide payment for under any circumstances.
Coding Notes and Annual Benefit Impact
| No codes listed |
Contract Definitions the Department Allows
Allowed contract definitions of “covered service”
The Department permits dental plans to define “covered service” in provider contracts using either of two definitions: (1) payment-based — a service is “covered” only if the insurer actually pays some portion of the provider’s bill (services for which the insurer pays nothing are “noncovered”); or (2) contract-based — a service is “covered” if the contract provides coverage for that service even when payment is prevented by limits (for example, annual maximums). The Department will continue to allow either definition to be used in contracts until the Legislature or courts define the term.
- Payment-based definition: insurer must actually pay part of the bill for the service to be considered “covered”; if insurer pays nothing the service is “noncovered.”
- Contract-based definition: a service listed as covered in the policy remains “covered” even when payment is not made due to limits like an annual maximum.
- Applied example: if a patient has exhausted an annual maximum, under the payment-based definition a filling would be noncovered (insurer pays nothing) but under the contract-based definition the filling remains covered because fillings are a contract-covered category.
- NDOI position: plans may choose either definition in provider contracts and the Department will adhere to this interpretation until changed by statute or court decision.
Definitions of 'Covered Service' (Practical & Contract-Based)
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