Delta Dental of Connecticut, Inc.
Out-of-Network Coverage Policy
Where No Network Providers Are Reasonably Available
Delta Dental of Connecticut, Inc. (“DDCT”) has a very robust network of participating providers. As a result, there will likely be very few situations when a covered member will not have access to a participating provider within a reasonable driving distance, reasonable appointment scheduling time, or where a participating dentist is no longer accepting new patients in the covered member's geographic area.
Participating providers agree to accept a discounted payment when treating a covered member and cannot balance bill a member an amount above what they have agreed to accept from DDCT. When a DDCT covered member uses a non-participating dentist who does not have a contract with DDCT, the non-participating dentist may balance bill the covered member for the difference between DDCT's payment and the provider's total charge.
In Connecticut, a covered member of an insured dental plan or contract that receives covered services from a Connecticut non-participating dentist shall receive the same benefit, including the same in-network cost-sharing as a covered member that received services from a participating dentist under the circumstances enumerated below. The covered member shall be required to pay the same amount that a covered member would have paid to receive the covered service from a participating provider in the same geographic area and DDCT shall either pay the out-of-network dentist's charge or negotiate a payment with the non-participating provider that holds the covered member harmless from any balance billing. The amount paid that exceeds the amount DDCT would have paid for the covered benefit shall not apply to either the covered member's annual maximum for the procedure, if applicable, or to the annual out-of-pocket maximum.
- DDCT does not have a participating provider of a type to provide the covered service to the covered person;
- A DDCT participating provider is no longer accepting new members;
- A DDCT participating provider is not able to provide the covered service without unreasonable travel, meaning that there is no participating provider within 45 minutes or 30 miles from the covered member's home in counties other than Fairfield County, where the distance and time for not having a participating provider is 20 miles or 10 minutes;
A DDCT participating provider is not able to provide the covered service without unreasonable delay, meaning that an appointment cannot be scheduled within the following time frames:
- within 10 days for non-urgent general dentist care;
- within 15 days for specialist care;
- immediately for emergency care;
- DDCT's network of participating dentists does not otherwise satisfy the statutory adequacy standards required by the Connecticut Department of Insurance1;
Where the covered member asserts one of the conditions listed above or appeals a determination of DDCT involving payment to the Connecticut non-participating dentist, DDCT shall review the covered member's communication and document its decision regarding its payment to the non-participating provider. DDCT shall respond to a covered member's request in a timely fashion appropriate to the covered person's condition. The time frame for issuing a response to a covered member is set forth in subsections (e) and (f) of C.G.S. 38a-591g2 for external reviews of adverse determinations and final adverse determinations. Upon request, a covered member's request to obtain a covered service from a non-participating provider shall be provided to the Connecticut Department of Insurance.
This policy shall not apply where a covered member elects to receive covered services from a non-participating provider based on the covered member's own decision and the criteria described above have not been satisfied. This policy shall also not apply to covered members enrolled in a self-funded plan governed by federal law.
This policy shall be effective October 24, 2018, and shall remain in effect until terminated or otherwise changed, consistent with applicable law and regulations.
1 C.G.S. 38a-472(f).
2 Consult the Law Department to assist in determining requirements under this provision.