missing tooth clause dental insurance

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A missing tooth clause is a plan term that bars payment for replacing a tooth that was lost or extracted before the current coverage started — the payer's own definition, from Delta Dental of New Jersey. It is a contract term, not a payer policy, and it is not universal: of the plan documents and payer policies read for this page, one Guardian individual plan in Utah carries a missing teeth limitation with a narrow carve-out (extraction within 12 months of the effective date and while covered under a prior plan), MetLife's group plan-summary form writes five separate prosthetic exclusions with a written-in carve-out for congenitally missing teeth, and Aetna's federal FEDVIP brochure states the same idea positively as the Tooth Missing but Not Replaced Rule. The TRICARE Dental Program, United Concordia's FEDVIP brochure, one Delta Dental Insurance Company group PPO, one Cigna Pennsylvania individual plan, and Colorado Medicaid carry no such clause at all, and Delta Dental of New Jersey publishes the opposite — a Missing Tooth Inclusion for members aged 16 and over on plans that cover restorative work. Three instruments are routinely mistaken for it: a replacement rule keyed to when the extraction happened relative to an existing prosthesis, a frequency-clock carryover that counts prior-carrier service dates, and an arch-level prosthodontic cap. There is no certificate of creditable coverage to submit: 45 CFR 146.115 superseded that artifact for periods beginning December 31, 2014, and stand-alone dental was never in its scope as an excepted benefit under 45 CFR 146.145(b).