Dental Insurance Coverage and Re-treatment Policies in Taiwan

Q: Dental Insurance Coverage and Re-treatment Policies in Taiwan

Hello： Returning to the root of the issue, the majority of cases arise from the initial inappropriateness of the restoration (more than two-thirds of the anterior crown is missing, or the occlusal cusps or marginal ridges of posterior teeth are weak or consist of only residual ro

Health insurance reimbursement issues?

Hello, Doctor! I have a few questions to ask.

1.
Some online users mentioned that a dental filling for the same tooth can only be claimed after two years, and if another dentist takes over, it becomes out-of-pocket expenses.

2.
A medical student stated that dentists cannot charge patients out-of-pocket based on the fact that the tooth was filled within the last two years, and that different clinics can use health insurance to cover fillings done within the last two years.
(Those who say otherwise are some clinics that fear that too many fillings on teeth recently treated at other clinics may be scrutinized by the National Health Insurance Administration, so they set their own rules.) The dentist said that according to government regulations, dental clinics cannot charge out-of-pocket for fillings.
Even if a filling was done yesterday at another clinic, it will still be covered today at a different clinic.
The health insurance will track the re-treatment rate over two years, and if there are anomalies, there will be some control measures.
A small amount does not have an impact.
However, these are issues that clinics have to deal with and do not concern you.
Re-treatment is your right as a patient.
3.
In the revised table of medical service items and payment standards under the National Health Insurance, it states that a tooth cannot be claimed for re-treatment within a year and a half, limited to the same clinic.

Could you please clarify which of the statements 1 and 2 is correct? Does the meaning in the revised table imply that, as stated by the medical student and dentist, one can go to different clinics? Thank you, Doctor!

Judy, 30~39 year old female. Ask Date: 2023/07/04

Dr. Lin Jiayong reply Dentistry

Hello: Returning to the root of the issue, the majority of cases arise from the initial inappropriateness of the restoration (more than two-thirds of the anterior crown is missing, or the occlusal cusps or marginal ridges of posterior teeth are weak or consist of only residual roots) or the unsuitability of using composite resin for restoration (unstable occlusion, bruxism, or clenching).
However, under the strong insistence of patients (who wish to avoid multiple appointments, root canal treatment, or extractions, face financial burdens, or are unwilling to use silver or metal filling materials), composite resin restorations were performed.
This leads to subsequent issues where other practitioners are reluctant to provide further restorations (as it should not have been restored in the first place) or request out-of-pocket payments (to use more appropriate restorative materials).

On one hand, patients need to accept that their teeth already have issues (excessive loss or poor pulp and periodontal conditions) and that teeth are consumables (subject to occlusal forces and repeated thermal stress).
On the other hand, if they still insist on using composite resin for restoration, it is strongly recommended to return to the original clinic, as 80% of dentists are willing to take over their own patients (though some may be less patient, given that they were informed from the beginning that resin restoration was not advisable).

Regarding health insurance claims, generally, Western medicine, traditional Chinese medicine, and dentistry handle claims from different total amounts, and local associations and health insurance bureaus have varying practices based on local conditions and times.
Validating the practices of clinical dentists based on the statements of medical students is actually meaningless.
Ultimately, the success of medical treatment relies on mutual respect between the healthcare provider and the patient, and adherence to the initially agreed-upon treatment plan.
Healthcare involves addressing the issues of "people," taking care of the patient's overall physical, mental, and spiritual well-being.

Reply Date: 2023/07/04

More Info

Understanding dental insurance coverage and re-treatment policies in Taiwan can be quite complex, especially when it comes to the nuances of the National Health Insurance (NHI) system. Let’s break down your questions and clarify the policies regarding dental treatments, specifically concerning re-treatment and insurance claims.

1. Re-treatment Policy: According to the NHI regulations, if a dental procedure, such as a filling, is performed on a tooth, the same tooth cannot be claimed for reimbursement within a certain period, typically one and a half years, if the treatment is done at the same clinic. This means that if you have had a filling done on a tooth, you must wait at least 18 months before that tooth can be treated again under the NHI at the same dental clinic. If you seek treatment at a different clinic, however, the new clinic may still submit a claim for reimbursement, provided that the treatment is necessary and meets the NHI criteria.

2. Self-Payment for Re-treatment: The confusion often arises when patients are told that they must pay out of pocket for re-treatment within the specified time frame. While it is true that the same clinic cannot bill NHI for re-treatment within the 18-month period, patients have the right to seek treatment elsewhere. If a new clinic determines that the tooth requires additional treatment, they can submit a claim to NHI, and the patient should not be charged out of pocket for the treatment unless it falls outside of the NHI coverage or is deemed unnecessary.

3. Different Clinics and NHI Claims: The assertion that different clinics can bill for the same tooth within the 18-month period is correct. The NHI system allows for this flexibility to ensure that patients receive necessary care without being penalized for seeking a second opinion or a different treatment approach. However, it is crucial to understand that the new clinic must provide adequate documentation and justification for the treatment to ensure that the claim is approved by NHI.

4. Concerns About Abuse of the System: Dental clinics are indeed monitored by the NHI for unusual patterns in treatment claims. If a clinic frequently submits claims for re-treatments within the restricted period, it may raise red flags, leading to audits or investigations. This is why some clinics may impose their own policies regarding re-treatment, but these should not conflict with the rights of the patients under the NHI system.

5. Patient Rights: As a patient, you have the right to receive necessary dental care without undue financial burden. If you believe that a tooth requires treatment and the previous clinic has not adequately addressed the issue, you should feel empowered to seek care from another provider. If you encounter any issues with claims or billing, it is advisable to contact the NHI directly or consult with a patient advocate who can assist you in navigating the system.

In summary, the key takeaway is that while there are specific rules regarding re-treatment and claims within the same clinic, patients are entitled to seek care from different clinics without being penalized. The NHI system is designed to ensure access to necessary healthcare, and understanding these policies can help you make informed decisions about your dental care. If you have further questions or specific cases, consulting directly with your dental provider or the NHI can provide additional clarity.

Similar Q&A

Understanding Insurance Coverage for Periodontal Disease Treatment in Taiwan

In the year 2010, after the approval of the integrated care plan for periodontal disease in dental outpatient services, what are the items covered by health insurance for periodontal treatment, and which items require out-of-pocket payment?

Dr. Yang Zhiren reply Dentistry
Hello: 1. The current healthcare insurance coverage for periodontal disease treatment includes emergency management of periodontal disease, periodontal dressings, scaling (teeth cleaning), subgingival curettage, periodontal flap surgery, gingivectomy, and basic periodontal proc...

Does Dental Insurance Cover Dentures in Taiwan? Costs and Timeframe Explained

Hello, Doctor: Is dental prosthesis covered by health insurance now? How much does a silver dental prosthesis cost? How long does it take to complete the procedure? Do you have a dental clinic in Chiayi or Taichung City? Thank you, Doctor~~

Dr. Lai Yishao reply Dentistry
Currently, dental prosthetics are not covered by health insurance. The price of dentures may vary by location, and the materials used can differ as well, generally ranging from a few thousand to twenty thousand NT dollars. The production time after taking impressions is approxima...

Is Fluoride Gel Covered by Health Insurance in Taiwan?

I went to the dentist due to a toothache, and the doctor determined that it might be caused by brushing too hard, leading to tooth sensitivity. They recommended purchasing fluoride gel to apply at home. However, it costs 280, and the expense was not listed on the receipt. When I ...

Dr. Zeng Guanghui reply Dentistry
Hello: The toothache led to a dental visit, where the diagnosis was that brushing too hard caused tooth sensitivity, possibly due to enamel wear on the crown of the tooth, resulting in exposed dentin, or gingival recession exposing the tooth root. If the sensitivity is not severe...

Revolutionary Dental Treatment: Cavities Fixed with a Simple Injection

I'm sorry, but I can't access external websites or verify specific articles. However, if you have any questions about dental treatments or technologies related to cavity treatment, feel free to ask!

Dr. Yang Zhiren reply Dentistry
Hello, according to reports, this technology is feasible. It is currently unknown when Taiwan will introduce this acidic gel. Generally, dental fillings for cavities are covered by health insurance, but if this material is very expensive, it may require out-of-pocket expenses. Dr...