ARE PEDIATRIC, ORTHODONTIC AND TMD SERVICES COVERED?
Dental practices and the public alike are navigating the maze of the Affordable Care Act (ACA) (a.k.a.: “Obamacare”), and how its healthcare mandates relate to dentistry. As part of the ACA, dental care for children is cited as one of the “Ten Essential Health Benefits,” but the reality is that pediatric dental plans may be optional. For children who have dental coverage, under Obamacare, pediatric dental plans allow for basic or expanded dental benefits and may also include orthodontic coverage.
Having studied the sections of Obamacare that pertain to dental care, I’ve found that much of the text is concerned with the definitions of “medical necessity.” Therefore, it is important for dentists to be familiar with this term. Keep in mind that the definition of medical necessity varies from state to state, so for more information, please check with the U.S. Department of Health and Human Services (HHS).
In talking with dentists around the country, the top ten questions I hear about the ACA are:
1. Q. How many people are expected to gain dental benefits as a result of the ACA?
A. The American Dental Association (ADA) estimates that as many as 8.7 million children will gain some form of dental benefits by 2018 as a result of the ACA. Roughly one-third of those children will be covered by their parents’ employer-sponsored insurance; another third will gain coverage through Medicaid. The remaining third is expected to be covered by new policies purchased from the health insurance exchanges. Since pediatric dental coverage is not mandatory when policies are purchased from the health insurance exchanges, many people suggest that this estimate is on the high side of what will likely occur.
A total of 17.7 million adults are also projected to gain dental benefits as a result of the ACA. The ADA projects that 5.3 million adults will gain extensive dental benefits, 85 percent of which are linked directly to Medicaid expansion in states that currently provide extensive adult dental benefits (AK, CT, IA, NC, ND, NM, NY, OH, OR, RI and WI). An additional 12.4 million adults are expected to gain emergency or limited dental benefits.
State-by-state projected changes as a result of the expansion of dental benefits due to the ACA are available for download online (http://www.ada.org/sections/professionalResources/docs/HPRCBrief_0413_3x.xlsx).
2. Q. What impact will the ACA have on dental spending and the number of dental visits?
A. It is estimated that the ACA will increase U.S. dental spending by an estimated four billion dollars, including an increase of 2.4 billion dollars in Medicaid dental spending plus an additional 1.6 billion dollars in expenditures by adults and children gaining private dental benefits through exchanges and employer-sponsored coverage.
The ACA is also expected to add 11 million pediatric private dental visits through expansion of dental benefits through the exchanges and employer-sponsored insurance plus 1.7 million adult private dental visits through expansion of dental benefits in the health insurance exchange.
3. Q. Why is pediatric dental coverage part of the ACA?
A. As noted earlier, pediatric dental care is cited as one of the “Ten Essential Health Benefits” under the ACA. Its inclusion was prompted (in part) by the 2007 death of an uninsured, 12-year-old Maryland boy named Deamonte Driver. Deamonte was killed by a bacterial infection that spread to his brain from an abscessed tooth. His story was widely reported as an example of limited access to dental care.
Although it is an “essential health benefit,” last year, states were informed by the HHS that pediatric dental coverage is optional. The change was the result of a court ruling, which held that while pediatric dental coverage must be offered on the health exchange, consumers cannot be required to purchase it. As a result, fewer children may actually gain dental benefits under the ACA than originally estimated.
4. Q. Does the ACA mandate coverage of specific pediatric and orthodontic dental services?
A. No. Under the ACA, each state is responsible for setting its own package of “essential health benefits” within HHS’s guidance. With the exception of Utah (where pediatric dental coverage purchased on the exchange is limited to coverage of semi-annual dental cleanings and sealants), most people will find that dental procedures covered as a result of implementation of the ACA are similar to their state’s Children’s Health Insurance Program (CHIP). Additionally, it should be noted that some states specifically include coverage of what they have defined as “medically necessary” orthodontics; others do not.
5. Q. Is our practice required to provide pediatric care at fees designated by the ACA?
A. No—not unless you are a contracted provider for Medicaid or a specific plan. In that case, you must provide pediatric dental services at rates designated by Medicaid or the specific insurance plan. Dentists may sign up as providers in the various HMO or EPO plans, such as Delta Dental Plans Association, which are offered on the Health Insurance Exchange or through brokers.
6. Q. What is the pediatric age limit? Does the ACA allow children to remain on their parents’ dental insurance plans through age 26?
A. The ACA is designed to provide pediatric dental insurance for patients under the age of 19; however, states have the flexibility to extend coverage. In addition, some dental insurers are voluntarily opting to extend the dependent age limit for their plans beyond age 19. Unlike medical insurance, however, there is no provision in the ACA that allows dependent children to remain on their parents’ dental insurance through age 26. Since states and plans vary, patients should be advised to check their current dental plan (or any dental plans they may be considering) carefully to confirm eligibility.
7. Q. Will dental coverage be part of medical insurance plans?
A. Since pediatric dental care is required under the ACA, basic dental coverage will be included in some health plans. In most cases, however, separate, stand-alone dental plans will be offered for basic dental services and preventive care. In fact, 99 percent of dental benefits are sold under a policy that is separate from medical coverage and this is not expected to change significantly.
Stand-alone dental plans are likely to have much lower deductibles than medical plans that also include child dental care, or possibly no deductibles, according to Delta Dental. They are also likely to have lower limits on out-of-pocket expenses than plans that combine medical and pediatric dental care. This may benefit families of children with acute dental care needs as well as those who want paid preventive care without having to wait until they have spent enough money to meet a higher deductible.
8. Q. Are adults required to obtain dental coverage under the ACA? Will medical insurance reimburse adults for TMJ splints and sleep apnea appliances?
A. First, no, the ACA does not require adults to obtain dental coverage. While some people believe that insurers may offer more stand-alone dental policy choices for adults and families as a consequence of the ACA, such stand-alone plans will not be subsidized.
Second, adults in some states may gain benefits for TMJ splints as well as Durable Medical Equipment (DME) for oral appliances for obstructive sleep apnea. One example is in West Virginia, where the state insurance commissioner has adopted guidelines for coverage of diagnosis and treatment of TMD and craniomandibular disorders (CMD) in medical policies as part of the ACA; other states have followed. It is important to note that this coverage is under medical (not dental) insurance.
9. Q. Are there any loopholes or technicalities we should be aware of with regards to pediatric dental coverage?
A. If the patient purchases insurance within Health Insurance Marketplace, the patient is not required to purchase pediatric dental insurance. In other words, although the health exchanges are required under the ACA to offer pediatric dental benefits, consumers are not mandated to purchase them.
When healthcare coverage is purchased outside of the Health Insurance Marketplace, however, the patient is required to purchase pediatric dental insurance.
10. Q. Will patients still have out-of-pocket dental expenses under the ACA?
A. Yes. If purchased from a federally-run exchange as a stand-alone policy, pediatric dental coverage can include annual out-of-pocket expenses as high as 700 dollars per child or 1,400 dollars per family, according to Colin Reusch, a senior policy analyst with the Children’s Dental Health Project, a nonprofit based in Washington, D.C. And the cost of stand-alone coverage cannot be counted toward the medical out-of-pocket limits built into the health care insurance policy. In addition, while some people may qualify for tax credits to help pay medical premiums, there are no tax credits for stand-alone pediatric dental plans.
As these questions and answers suggest, navigating through the ins and outs of the ACA may be challenging—particularly for dental practices that accept large numbers of Medicaid patients. We will undoubtedly learn more as the law is implemented. In the meantime, with 26 percent of preschool age children, 44 percent of kindergarteners, and more than half of adolescents experiencing preventable tooth decay, the intent of the ACA to expand dental coverage to millions of children is one we can all rally around.
“Additional Information on Proposed State Essential Health Benefits Benchmark Plans,” The Center for Consumer Information & Insurance Oversight, Centers for Medicare & Medicaid Services, accessed May 1, 2014, http://www.cms.gov/cciio/resources/data-resources/ehb.html.
American Dental Association. Potential effects of the affordable care act on dentistry. August 8, 2013. http://www.ada.org/sections/advocacy/pdfs/August_8_2013_Effects_of_ACA_on_Dentistry.pdf (Accessed online 3/25/14)
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Rinde, M., Affordable Care Act’s dental coverage for children loses its bite. NJ Spotlight. January 22, 2014. http://www.njspotlight.com/stories/14/01/20/change-in-aca-rules-means-fewer-kids-will-have-dental-coverage/ (Accessed online 1/27.2014)