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# What is a Missing Tooth Clause? Its Importance and How to Avoid It?

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- December 13, 2024

Are you one of those who’ve never heard of the term missing tooth clause? Well, you’re not the only one in the dark. Many patients and even dental teams across the US find this clause complicated. It is hidden somewhere in the fine print of dental insurance plans. It is there for a reason.

We know digging deep into the fine print can be time-consuming and painstaking. However, being in the dental industry, someone concerned with reimbursements and finding out a patient’s out-of-pocket deductible, you should be ready to dive in.

Patients having dental coverage think they’re covered for any necessary dental procedure until they visit a dentist. However, the situation turns upside down when a medically necessary procedure is turned down owing to a missing tooth clause. Or the dental office, after checking details, informs the patient that the insurance doesn’t cover the bridge or implant.

Want to know what exactly the missing tooth clause is? Let’s tell you!

## What Is a Missing Tooth Clause in Dental Insurance?

The missing tooth clause or MTC is a special clause in the insurance fine print explaining that the coverage plan doesn’t reimburse for any treatment done to replace an extracted tooth or missing teeth before the starting date of the policy.

Simply put, if the patient gets a tooth removed prior to the starting date of the policy, it will be considered a pre-existing condition. Thus, insurance will not cover such a pre-existing condition. For instance, a procedure performed to replace an extracted tooth with a fixed partial denture, implant, or removable partial.

## Reason for Non-Coverage

The reason to deny such a procedure lies in the cost incurred. Both dental specialists and patients know that dental implants, bridges, and root canals are pretty expensive. Another technical point behind this clause is that people with extracted or missing teeth would buy a dental insurance policy, have their teeth replaced with an implant, i.e., partial denture or bridge, and cancel the policy afterward.

Now, to combat this unfairness to insurance companies and current policyholders, this clause serves as a protected measure so that the existing policyholders are not unduly burdened. So, as someone thinking of buying a dental policy, you have to go through the insurance plan to know what the missing tooth clause states. Here’s an example:

Here, you can see how cunningly they’ve tried to conceal the missing tooth clause. However, this is it. You need to be clever to find out what’s included, etc.

## No Missing Tooth Clause in Dental Insurance

As a patient, if your coverage plan doesn’t have a missing tooth clause, then you may be covered for the treatment of a missing tooth. However, you’ll still have to consider the following conditions.

1. Eligibility date
2. Waiting period
3. Least expensive alternative treatment (LEAT)
4. Implant coverage and benefit year
5. In and out-of-network benefits.
6. Percentages and deductibles
7. Maximum allowance and remaining amount
8. Other plan limitations or exclusions

All or any of these conditions may affect your out-of-pocket expenses. Also, it is important to be vigilant when buying a dental insurance policy. Ask questions to verify your eligibility and coverage details. Lastly, research and match plans from different coverage providers to find the best that suits your needs.

## Importance of Understanding the Clause for Patients

As a patient, if you have a missing tooth, you must know whether this clause is present in the contract or not. According to PubMed Central’s studies, the occurrence of tooth loss in adults aged between 20-64 years is 35.7%.

However, a survey conducted by CDC on people over 65 years of age showed much worse results. The study shows that 26% of people have eight or fewer teeth. 17% have lost all of their teeth. Adults with low income, less than a high school education, or who smoke are 3 times more likely to lose all their teeth.

The stats mentioned above show that missing teeth is quite normal. So, if you, your family member, or any of your acquaintances are missing one or multiple teeth, going through the coverage’s fine print becomes equally important.

Buying a coverage plan that has a missing tooth clause can be frustrating. Be careful. Otherwise, you’ll be paying a hefty insurance amount for a plan that doesn’t cover teeth replacement.

Treatment for missing teeth includes:

- Dental bridges
- Dental implants
- Removable dentures

Your claim won’t go ahead in the presence of this clause if you want to replace a missing tooth. The dental specialist may resubmit it, but they will face rejection every time. The insurance company will deny it due to a missing tooth clause. In simpler words, you’ll solely bear all the costs from your pocket and insurance won’t help you.

## The Confusing Part of This Clause for Dental Professionals

One big reason why dentists are confused about this clause is that it mentions 50% coverage for prosthesis. If patients and the provider don’t understand the details or miss important information, it may lead to the patient incurring significant costs for the treatment – more than estimated.

Another drawback is that most practice management software may not be able to calculate the exact out-of-pocket costs in case a missing tooth clause applies. Only an experienced professional who pays close attention to details can point it out.

Also, inexperienced people may need help understanding the technical language used in the terms and conditions section and may find the conditions difficult to comprehend. Moreover, the conditions change from time to time. This is the reason why we suggest proper dental billing training for dental professionals and their teams.

## How Important It Is to Understand The MTC for Dental Teams?

Dental teams should be vigilant and must know whether a patient’s plan includes MTC. It is important because the coverage may consist of other dental treatments like implants, fixed or removable partial/bridges, or dentures.

The MTC may apply to the patient’s insurance plans, resulting in limited coverage for replacing missing tooth/teeth. In case the MTC does apply, the payor will not pay for the dental procedure, leaving the patient to pay for it entirely, which could be costly as all treatments mentioned above fall under major dental procedures.

Here’s a situation to make it easy for you. If a patient already has an implant, bridge or denture before the coverage starts and wants to replace an old fixed denture, the MTC won’t apply. This is because their tooth was replaced a long time ago, and now you are replacing the fixed denture.

As a dental professional, all you need is to convey the coverage provider about the date of previous placement, the reason, prognosis, X-ray and any documentation mandated in the plan. Don’t forget to review the coverage plan details concerning dental replacement policies. Usually, there are 5 to 10 years on fixed partials, bridges, crowns, etc.

All this hassle on your part can save the patient a lot. However, all this effort requires a deep knowledge of the MTC and billing guidelines. This is why a dental professional and the biller must be updated and educated on different clauses included in the policy.

## Dental Insurances Having a Missing Tooth Clause

All companies providing dental insurance in the US can have a missing tooth clause. However, it depends on the specific contract. This condition is mostly added to the plan to lower the premium, which eventually leads to reduced monthly payments.

Leading dental insurance companies with a missing tooth clause in their plans

1. Cigna
2. Principal
3. United Healthcare
4. Aetna
5. Metlife
6. Unum
7. Delta Dental
8. Sun life
9. Guardian
10. Beam

Now, here’s the tricky part you need to be careful of. Although these companies do include the clause, still you have to be smart to go through the fine print. If you don’t see it anywhere, we suggest giving a call to confirm from the insurance agent.

## How to Avoid the Missing Tooth Clause?

Now, we know that misunderstanding the MTC may pose serious operational and financial challenges to the practice and the patient. Don’t hit the panic button yet. We’ll tell you how to avoid this complicated clause in your dental policy.

### Buy A Dental Insurance Policy as Early as Possible

We all know how fast and busy our lives have become. People are busy and always in a hurry. So, many people suddenly decide in favor of a major dental treatment and want it quickly – like within a day. For instance, they’re missing one or multiple teeth or want a crown treatment.

They’ve already postponed their dental policy way back. And all of a sudden want to have a dental treatment to rectify the problem. And that too without a valid dental plan. Patients have themselves to blame for this. They could’ve continued with the insurance to avoid the problem.

One way to avoid the MTC is by buying a dental plan before you even need it. According to some people, this is the shortcut to saving tooth replacement costs. If you’re suffering from a missing tooth or teeth and buy a plan after it, the policy will automatically cover the process.

Seniors or those who’re about to retire must buy a policy one year before they go off their organization’s dental insurance plan and enroll with Medicare.

Initially, you may think that paying regular premiums for insurance you don’t need is a hefty waste. However, many dental policies come with a waiting period of 12 months before you’re eligible for major dental procedures. If you lose teeth, the plan will cover the replacement. Simply saying, investing in an insurance now saves you huge upcoming costs.

### Dental Discount Plans

Another way to save costs is a dental discount plan. There’s nothing in your policies terms and conditions like a discount plan. However, it is a deal between you and your dentist that they will charge you less than what they normally do for the procedure.

Dental discount plans can serve you tremendously. They work and can save huge costs if you find a dentist who accepts these plans. Many dentists don’t. One thing to remember is that you may have to switch your dentists and find someone who accepts and honors the discount plans.

If you’re interested in this option, here’s some helpful content regarding how a dental discount plan is betterd than dental insurance. If you find a dentist who accepts a dental discount plan and is skillful, you can save on your missing tooth treatment.

Lastly, don’t forget to confirm that the dentist accepts the dental discount plan by contacting their office before enrolling.

### Get A Dental Policy That Doesn’t Involve MTC

As we’ve mentioned above, many dental insurance providers sell policies come with MTC. So, if you or your family member has dental insurance for years and you or they have a missing tooth before the coverage starts, the company won’t be liable to cover the treatment.

You may ask your dental specialist to submit the claim to the insurance. However, the providers may ask for your dental records. Most likely, the previous records will have a note mentioning the missing tooth or teeth. So, your request won’t go through.

Two of the leading names in dental insurance world that don’t have a MTC are Careington Dental and Delta Dental. They provide coverage for missing tooth replacement treatment even if the tooth was extracted before you bought the coverage.

However, as you know, the teeth replacement procedure is a major service, and the insurance mandates a 12-month waiting period. So, you’ll have to buy the policy 12 months prior to the treatment and pay the premium regularly to be eligible for this clause. It could also involve some other terms and conditions in the fine print, which you should never miss.

## Changing Insurance During the Process

Let’s suppose your insurance includes a missing tooth clause. After buying it, you must wait before going through the tooth extraction process. But after the extraction, you change your job and, with it, get a new policy that comes with an MTC. Now, you want to replace the missing tooth with a bridge.

If this situation arises, the insurance company will deny the bridge treatment as the new plan has the MTC. You need to be careful when changing insurance in the middle of the process. If the situation arises, be mindful that the following policy may also have the clause. So, your waiting time could expand.

## How to Avoid a Heavy Dental Bill in This Situation?

If you don’t want to pay a heavy dental bill, ask your dental service provider to submit a pre-determination before the treatment begins. This advance notice or predetermination is always handy and recommended before any major dental treatment, which can result in a hefty bill.

The following services fall under the major dental procedures:

- Dental Crowns, tooth caps
- Dental bridges
- Dental implants
- Complete dentures

Once you request for a predetermination to know about the estimated costs, the dentist will send it to you, giving you an idea of how much you could pay for the treatment. There’s one disadvantage of pre-approval, i.e., it takes around two weeks to get a response from the insurance company informing whether they’ll cover the procedure or not.

## Can You Appeal Against a Denial?

Well, you can. But after providing all the information regarding MTC and how to avoid it, etc., we’ve got some not so good news for you. Unfortunately, your appeal against the insurance denial due to an MTC will be rejected. The worst part is it cannot be overturned, as it was always there in the contract when you bought the policy.

You cannot request to overturn the decision, nor can you change the terms and conditions set out in the fine print. You need to be aware of whether this condition is part of the plan you’re about to buy. Contact the insurance company to clear all confusion and also go through the fine print to ensure that you aren’t misguided. Stay vigilant!

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