Help Re Child Orthodontia

[policy doctor]

I hope you good souls can give me some guidance here. I'm working with a single mother whose 8 yr old son is going thru orthodontia treatment now. She has changed jobs 2 months ago and now again starts a new one in Sept so her current group plan is out end of month.

Humana/Silver PPO off-exchange has the childrens dental but orthodontia benefits not really explained. She wants to know if they will cover his remaining treatment and how much is her portion. How do I answer that?

I called CSR and really, they don't know. Best answer is the dentist would have to send in the paperwork and the claims dept would sort out what they would pay. Very vague..I guess it's still considered cosmetic? tho client says his primary dentist insists he needs it.
Is there a generic answer for this case? Should I do a 3 way call with the co or just have her call the company direct? I don't want to get roped into an e&o claim.

 

[Yagents]

She can maybe keep the current dental plan she is on through cobra separate from the medical

 

[LGilmore]

the ACA requires minimal childrens coverage, basically check ups and some work. ortho is never mentioned in any plans beyond Not covered.

If she goes to a new employer their plan may cover ortho, but this may also be a pre-ex situation. the ACA removed pre-ex on medical, not dental. That would be up to the carrier.

Ortho coverage is very limited anyway. Usually pays about a quarter of the cost. the rest is on the family. If she had prior coverage for this and is eligible for Cobra, she might check and see if her former employer will allow unbundling their plan. Some do, some don't. Entirely their option.

Good luck

 

[taterpeeler]

0rtho covered as long as medicaly ness. with max opkt I think 700 per year... 2 year wait.... might check and see if prior cred coverage will eliminate the wait.... bcbs tx separate stand alone dental... humana dental is jacked... lumped into the health plan and pays at 50% I don't know about much else and this is what my rep told me... pays after cy deductible

 

[AllenChicago]

the ACA requires minimal childrens coverage, basically check ups and some work. ortho is never mentioned in any plans beyond Not covered.


Good luck

Here's a Benefits Summary for Humana's best Silver Plan w/imbedded Pediatric Dental for central Georgia.

Link: http://apps.humana.com/marketing/documents.asp?file=2149264

The number of exclusions are greater now than before ObamaCare. The Pediatric Dental Exclusions page says that Orthodontic services are NOT COVERED, unless the medical benefits section higher up in the document says that they ARE COVERED. You look higher up in the document in the Pediatric Dental section, and it says, "See your policy's medical schedule of benefits" to learn which Orthodontic services may be covered.
WTH!?

 

[LGilmore]

Looks like there is a 4250 deductible to meet before any dental is covered as they combine all services to one deductible.

 

[taterpeeler]

Looks like there is a 4250 deductible to meet before any dental is covered as they combine all services to one deductible.

that's what I told you

 

[policy doctor]

And when I asked the Humana csr if I could get a copy of medical benefits PLAN that is sent to consumers, there was the usual hem and haw and no, they had nothing to email me either.

There is no cobra available to her because she left almost 2 mos ago. Had another job while covered under prior group and is now in training for new job starting Sept 01 that has no employee benefits.

Intricacies.
I usually read exclusions in SOB's which tips me to what is covered or not.
Thanks for the responses....

----------

Reading into the "exclusions" section I think they only pay ortho if there was a catastrophic damage to jaw/teeth...such as an accident, chemo, burns, etc. Would make sense to lump it in with medical.

 

[LGilmore]

If her former employer offers cobra and she hasn't signed off, I think she has still an opportunity to enroll. I think it is up to 6 months off the top of my head, unless she's signed off already. She just would have to catch up the premium.

 

[policy doctor]

ok..i'll tell her to ask. Tks for tip.