Dentistry Could be Shaped by New Affordable Care Act Rules

Laird Harrison

November 29, 2012

Eleven million adults may drop their dental insurance as a result of a requirement in the affordable care act that they buy dental benefits for their children, the National Association of Dental Plans (NADP) is warning.

The changes could come about as a result of rules published online November 26 by the US Department of Health and Human Services to define what "essential benefits" health insurance plans must include when sold to individuals or small groups, such as companies with fewer than 50 employees. (Different rules apply to large employers.)

The essential benefits are listed in the law itself, and one of the benefits is "pediatric services, including oral and vision care." However, despite its length (it runs 2409 pages), the law does not spell out the details of what "pediatric services" must include.

The November 26 rules clarify that states must use as benchmarks the benefits provided in one of the following:

  • the largest plan by enrollment in any of the 3 largest products in the state's small group market,

  • any of the largest 3 state employee health benefit plans options by enrollment,

  • any of the largest 3 national Federal Employees Health Benefits Program plan options by enrollment, or

  • the largest insured commercial health maintenance organization in the state.

If these plans do not include dental benefits, then the states must supplement them with the dental benefits provided by either the Federal Employees Dental and Vision Insurance Program (FEDVIP) dental plan with the largest national enrollment or the state's Children's Health Insurance Program (CHIP).

Colin Reusch, a policy analyst for the Children's Dental Health Project, told Medscape Medical News that this rule was "good news" because these benefits are fairly comprehensive.

The NADP is not so sure. The organization estimates that such a plan will cost $27.90 per child per month if the FEDVIP standard is used, and $32.05 if the CHIP standard is used. These estimates include medically necessary orthodontia with 50% coinsurance (meaning the insurer and the patient each pay half).

That would be an increase from about $21 per child per month in a "typical small employer dental preferred provider organization" as it exists today without orthodontia benefits, or $23.80 including orthodontia with 50% coinsurance.

On the basis of consumer surveys, Evelyn Ireland, executive director of the National Association of Dental Plans, told Medscape Medical News, she believes that forcing adults to pay for more expensive plans will lead about half of the 22 million who now are paying for dental benefits through small companies to drop those benefits.

In contrast, the Pew Center on the States has estimated that 5.3 million children would gain dental benefits through the Affordable Care Act. (Some adults also might gain dental benefits through Medicaid; it is not clear whether this would mean a net change in the total number of people covered.)

Not everyone agrees that millions of adults would drop their own benefits. "That's certainly a possibility, but traditionally dental benefits for children have been relatively inexpensive and I see no reason that they would be unaffordable" under the new regulations, Reusch told Medscape Medical News.

The NADP is also concerned also because the new rules do not explicitly allow stand-alone dental plans to meet the requirement of "essential benefits" outside the insurance exchanges that the law requires in each state.

Stand-alone dental plans are allowed inside the exchanges, but Ireland told Medscape Medical News that regulators have indicated they do not have the legal authority to say that stand-alone dental plans can meet the requirements of the Affordable Care Act outside the exchanges.

If dental and medical plans are combined in the small-group market outside the exchanges, Ireland warns, then about 26 million children will have to change their coverage and might risk ending up with a dental plan that does not include their current dental office among its providers. "It was pretty disappointing that our top-priority issue was not addressed in these rules," she said.

For too long dental has been considered separately. We would love to see the mouth be put back in the body. Colin Reusch

Some organizations of dentists such as the California Dental Association also support the separation of dental plans and medical plans. However, Reusch argues that patients might be better off with dental and medical benefits folded into comprehensive health plans. "It would allow better coordination of care," he said. "For too long dental has been considered separately. We would love to see the mouth be put back in the body."

The November 26 rules leaves some questions unanswered. One of the most important is whether people who buy medical plans through the exchanges must also purchase separate dental plans for their children. Ireland and Reusch both said that federal regulators appear to be leaning toward leaving it up to each state to decide whether to require that.

If that happened, the law might expand dental benefits to far fewer children than originally estimated.

"That's still an issue that we're concerned about," said Reusch. "Consumers tend to gravitate toward the lowest-cost option."

The commentators have disclosed no relevant financial relationships.

"Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation." US Department of Health and Human Services. Full text