How to Get Around the Missing Tooth Clause in Dental Plans

How can you avoid the missing tooth clause in many dental insurance plans? If successful, you could lower your costs for dentures or implants significantly.

You have two possible strategies with very low odds of bearing fruit. But given the stakes, you owe it to yourself to see if you qualify.

Finding dental insurance that covers implants or dentures for missing teeth is one route with three possible avenues: Medical plans, Medicaid, and group coverage.

Filing an appeal with your existing dental insurance is the other route. Of course, you will need a precise definition, which you should reference in your policy documents.  

Dental Insurance Without Missing Tooth Clause

Buying a new dental insurance policy without a missing tooth clause is a viable way to get around the exclusion – but only for a tiny subset of patients – because this type of coverage is tough to get.

Free dental implant programs might be the only alternative for low-income patients unable to find a viable workaround or alternative plan.

Medical Plans

Medical plans could work as dental insurance with a missing tooth clause under narrow circumstances. Under the Affordable Care Act, these policies must cover pre-existing conditions with no waiting periods.

Medical insurance covers dental implants when medically necessary. Qualifying services are “appropriate to the evaluation and treatment of a disease, condition, illness, or injury and are consistent with the applicable standard of care.”

Medicaid

Medicaid could act as dental insurance with no missing tooth clause in a large swath of the country. This publicly-funded program covers pre-existing conditions and often pays claims retroactively for newly enrolled recipients.

Medicaid covers dentures for adults in thirty-three states. Therefore, your plan could pay for partials or a complete set of false teeth regardless of when they fell out.

Of course, you must meet the low-income criteria to qualify for Medicaid.

Group Plans

Group dental insurance without a missing tooth clause is abundant, but your employer has to provide it. Insurers are more likely to cover this specific pre-existing condition as a concession to get large employers to offer the benefit to employees.

However, you must sign up at work at the first opportunity. The issuing company will probably impose the missing tooth clause on employees initially opting out of the coverage.

In other words, you cannot decline to pay the premiums and sign up later after the dentist extracts several teeth. The insurers are aware of this game and take steps to protect themselves.

What is the Missing Tooth Clause?

With dental insurance, you must understand what a missing tooth clause means to get around it without signing up for a new plan. Your existing policy might contain a definition similar to this.

“If an insured has lost one or more teeth before the policy effective date, we will not pay for a prosthetic device to replace them.”

Dental implant financing could be a better avenue for patients with higher incomes who waited too long to enroll in a policy or experienced a long gap in coverage.

Pre-Existing Condition

A missing tooth clause in dental insurance is similar to a pre-existing condition exclusion – only more specific. The issuing company is protecting itself from people who decide to forgo paying premiums until after the need for treatment becomes apparent.

The Affordable Care Act does not require dental insurance to cover pre-existing health conditions. Therefore, expect to encounter several roadblocks when seeking treatment.  

  • The missing tooth clause would apply to dental implants because they represent the most expensive prosthetic devices to replace lost incisors, molars, and bicuspids.
  • The missing tooth clause would also apply to dentures and partials even though they are the less costly alternative to replace lost incisors, molars, and bicuspids

Filing Appeals

The best way to get around the missing tooth clause in your dental insurance is to file a well-supported appeal. Read your policy language carefully to know what facts to include in your petition.

Your appeal might need to include evidence of prior coverage if the legal language consists of a phrase similar to this.

“We will pay for fixed bridges, dentures, and implants to restore teeth extracted within six months of the policy effective date if this coverage replaces a prior plan.”

Your appeal could require evidence that you were born without choppers if the legal language includes a phrase similar to this.

“Treatment of congenitally missing teeth is not covered under your plan unless you are replacing a current fixed bridge or denture.”