Is there a federal law that children must be allowed to have dental services done in an outpatient facility?

Question

Trying to find out if insurance carrier can deny dental services for a child in an outpatient hospital setting simply based on anxiety or fear. Does the child have to have a mental disorder/physical handicap etc? Is there an age limit? Does it have to be for oral surgery only or would simple cleanings or fillings be enough?

Answer 1

There's no federal law which mandates this service. Actually, there are very few ERISA laws that mandate specific benefits that must be included in policies offered via an employer. The good news is that, if your benefit plan is fully-insured, it's governed under state insurance law, not federal law. Call your state insurance commissioner's office for a definitive answer to your question (if you work in another state, call that state's insurance commission).

Some states DO have laws mandating this type of service be covered; my state is one of them.

Answer 2

There isn't a federal law that would handle that situation. (If there were going to be any sort of law that would cover the situation you described, it would more likely be a state law...not federal. I doubt that's the case, but if you're going to try to do some research state law would be the place to start. I can't imagine any instance where cleanings or fillings would be authorized in a hospital setting...maybe oral surgery, but even that would be a stretch just for anxiety.)

I have sometimes seen dental services authorized to be done in an outpatient hospital setting. However, in each of the instances there was a physical reason for doing so, not an anxiety/fear thing. (For example, in one situation the patient had a heart condition which made it risky to administer anesthesia in the dentist's office. So, the insurance company I worked for at the time authorized the services to be done in an outpatient hospital setting.)

Answer 3

No, there is no federal law. Insurance companies can deny anything they want to. It's up to the patient to know what is covered under their plan, and if dental work in an outpatient setting is not a covered service, there is nothing you can do to force it to be paid.

Answer 4

Most people, including children, go to a dentist's office for dental work, not to a hospital. They would be outpatients, as you referred to them. Anxiety or fear is treated by the dentist in his/her office. No child would have to have a mental disorder or handicap. Age limits are only that you must have teeth! Cleanings and fillings are done in the dentist's office.

Answer 5

No, there isn't.

It's a judgement call on the part of the dentist.