With the headlong pursuit of mandated health care, one benefit has been largely left to fend for itself. Dental care has been treated by the health care industry for many years as that red-headed stepchild that parents are not sure how to deal with or where to put them. Because the primary issue with government and commercial insurance has been focused on primary medical and major medical care, the dental business has been trying in earnest to keep up, but seemingly not able to keep pace.
According to the Washington Post, the health care law outlines 10 major benefit categories that all insurance plans will need to cover by 2014. These are known, in the health care law, as the “essential health benefits,” the medical services that are crucial to keeping Americans healthy. The essential health benefits include things like maternity care and hospitalizations. It includes “pediatric services, including oral and vision care.” There’s nothing, however, that would require coverage of such services for adults.
This is actually true of a lot of public insurance plans, as reported in the Washington Post. Medicare barely covers much in the way of dental benefits (AARP offers private, supplementary plans for dental coverage). In Medicaid, 22 states either offer no dental coverage at all or only do so in emergency situations. Dentists, meanwhile, haven’t exactly been gunning to be included in public health systems. Staying outside of the insurance system means they can charge whatever prices they want, without a health plan pushing back.
This is a situation that troubles a lot of public health advocates. About 33 million Americans live in areas where there aren’t enough dentists to meet oral health care needs. Research has linked poor oral health to increased use of emergency services and hospitals, and higher risk for diabetes and heart and respiratory diseases.
For the most part, thanks to Obamacare (with the exception of a pediatric dental mandate), the vast majority of people who have dental coverage are going to need help come 2014. Dr.Bicuspid.com reports that while 5.3 million children will gain dental coverage in 2014 thanks to the Patient Protection and Affordable Care Act, up to 11 million adults could drop their own dental coverage when their children are covered separately, according to the National Association of Dental Plans. Parents who switch to dental coverage under their medical insurance may have to change dentists.
Currently, adult and children’s dental plans are mostly sold as group plans offered by employers. These dental plans are separate from medical plans. As one of the 10 essential health benefits under the PPACA, pediatric dental benefits will be part of medical plans sold outside of the insurance exchanges.
Pediatric dental plans also will be sold in insurance exchanges, both packaged with medical plans and as standalone dental plans—choices include pediatric dental embedded in the plan, as a rider, or as a standalone plan. While large companies (more than 50 employees—in 2016 this will increase to 100) won’t be affected by the upcoming changes in 2014, employees in small groups will have to decide this year how to get the dental benefits mandated for their children.
What that means is the dental coverage that nearly 23 million children now have as part of their parent's policy in the small group market will be duplicated by their medical coverage beginning in 2014, according to Evelyn Ireland, the executive director of the National Association of Dental Plans. About 5.3 million children are expected to gain dental coverage next year, mostly through public programs such as Medicaid or the Children's Health Insurance Program.
To avoid duplication, parents have to decide by the end of this year whether to take their children off their separate dental coverage. If they do, they may have to change dentists for the children, depending on which dentists are in the medical carrier’s network. From a dental insurer’s perspective, the changes will probably move some of their customers from group plans to individual plans, according to Joanne Fontana, an actuary who tracks health insurance for the actuarial and consulting firm Milliman. This marks the first time there will be a need for pediatric-only plans which are mandated by the PPACA.
“Some dental insurers aren’t too anxious to jump into the individual marketplace,” Fontana told DrBicuspid.com. “With the exchanges, you have an individual marketplace where people will be purchasing pediatric oral care, so insurers will be making sure they position themselves and their product so they can attract business. It’s also important to understand that people on the exchanges may look a little different than the group of people that have historically been covered under employer-sponsored plans.”
The kind of coverage employers will offer once the exchanges are in place remains to be seen. “I think dental is still viewed by employers as a value-added benefit, and you want to offer good benefit packages to your employees,” Fontana said. “The broader issue is, are employers going to keep offering any kind of coverage, or are they going to say, ‘Nope, go buy medical and dental coverage wherever you want.’”
The PPACA provides subsidies for those with lower incomes (under 400 percent of poverty level) who opt for coverage in the exchanges, but only if an employer does not provide adequate coverage.
Individual dental plans—along with small group dental plans in and out of the exchanges—are going to explode in demand and popularity. Finding good dental coverage, whether part of a qualified health plan, a standalone dental insurance product, or a discount dental plan, should be number one on your health care priority list, right after you figure out your primary medical coverage. The problem is that many people may not be able to afford coverage for themselves if they have to choose between their own care and a plan for their kids.
The closer 2014 gets, the greater realization of sticker shock is going to hit the public. To quote a line from a recent apocalyptic film: “May the odds be ever in your favor.”