Can My Dentist Charge Me More Than My Dental Plan Allows?

Many dentists sign contracts to provide dental services to patients that have a particular dental benefit plan.  Part of that contract requires the dentist to accept a set fee for a defined procedure.

Amalgam Composite FillingHowever, all procedures are not the same.  A "filling" for example, can be an amalgam filling or a composite - tooth-colored filing.  Each has a separate dental code and price with the tooth-colored filling generally more expensive.  See the example Explanation of Benefits image below.

However, most dental benefit plans do not "cover" a tooth-colored filling and many patients do not want a silver, or amalgam filling.  Dental benefit companies were forcing dentists to accept a lower price (amalgam) for the patient receiving a higher priced procedure (tooth-colored filling).

To offset this inequity for the dental office, the NDA passed LB 810 in 2012, now 44-7,105 in the Nebraska Statutes.

Section 44-7,105 prohibits a dental benefit plan from "limiting any fees charged for dental services that are not covered by the policy, certificate, contract, agreement, or plan."

Because the Nebraska Department of Insurance has interprested this statute both ways, the NDA filed a lawsuit for the court to clarify the intent of this language, specifically looking at the Legislative History.  The Court heard the Summary Judgement motion on September 27, 2021.  In December 2021, the Court refused to settle the issue as requested. 

However, during this litigation the NDA received a letter written by NDOI attorney Laura Arp to Ameritas in 2015. - specifically addressing the NDA's noncovered services statute.  

In the letter to Ameritas, Ms Arp states, If Dental Benefit Plan never pays for the more expensive "alternate benefit", then the more expensive "alternate benefit" is not “covered by the policy” and Dental Benefit Plan cannot dictate the price for that service.

Ms. Arp's Affidavit dated August 10, 2021 is consistent with her 2015 letter.

This sentence applies to all of our non-covered situations.  If Dental Benefit Plan never pays for ______________, then ________________ is not “covered by the policy” and Dental Benefit Plan cannot dictate the price for that service.

Just fill in the blank with a common non-covered situation - A third cleaning in a calendar year; fluoride treatments for children over 18; dental services within 6 months of starting a job (waiting period); dental services exceeding the annual cap.

Dental Benefit Plan booklets describe what the plan covers.  The example below is a Blue Cross Blue Shield booklet explaining dental benefits.  They have specific sections titled "Waiting Periods" and "Non Covered Services."

Alternate Benefit Example of Non Covered Service

In the above example, the dental benefit plan that "does not cover" tooth-colored fillings.  However, the plan will provide an "alternate benefit," which is the reimbursement cost for an amalgam filling.  Because the dental benefit plan did not cover (or pay for) a tooth-colored filling, then the patient must pay the difference between the amalgam "alternate benefit" and the tooth-colored filling fee.

The image below is an example of an EOB (Explanation of Benefits) from Delta for a patient that received a tooth colored filling (D2393) and the Delta plan only covered an amalgam filling (D2160).  Delta is paying an "alternate benefit" of $133.80 which is the amount the contract provides for an amalgam filling (D2160).  In this example, the patient is paying 20%, or $26.76, for their portion of the $133.80.  However, the patient is also responsible for the difference in the amount of the composite filling ($221.00) and the $133.80 amount that Delta calculated for an amalgam filling, for a balance of $87.20.