The Affordable Care Act: What about Dental?
A roll-out of the possible avenues for general healthcare under the ACA begins in October, 2013 to be implemented beginning in 2014. Insurance coverage changes already in effect for several years have been the ability of young adults under the age of 26 to be covered under a parent’s policy, as well as a prohibition for denial of coverage for a child with pre-existing health problems. Adult coverage for pre-existing conditions will be a part of the “rules” starting in 2014. Prior to this change, individuals who have insurance at their place of employment, but change jobs, might find themselves unable to obtain coverage at their new workplace. Insurers have used the pre-existing condition clause for decades to successfully avoid taking on persons who might need medical treatment.
Of course, possible dental coverage is of prime interest to our profession and our patients. As of January 1, 2014 dental coverage will be a required inclusion in individual and small group market plans, both within private markets and also “exchanges” being set up under federal guidelines, but only for children under age 19. According to the ADA, all states except for Utah (which is offering only a preventive plan) have selected existing state Children’s Health Insurance Program (CHIP) plans or the MetLife High Option plan from the Federal Employee Dental and Vision Insurance Program as their benchmark plans for exchanges.
Of concern to dental insurers is the fact that within the exchanges run by the federal government, a dental “essential health benefit” must only be offered, however in the individual and small group markets outside the exchange, the dental EHB must be purchased. State exchanges do not face this requirement, and according to the ADA, few states have chosen to mandate dental benefits. Even without a mandate, increases in dental coverage for previously uncovered persons is expected.
- Actual dental visits through 2018 could add 11 million pediatric and around 2 million adult private dental visits through the exchanges and regular employer sponsored insurance.
- Dental spending through 2018 will likely increase by $4 billion nationwide, with the largest effect seen in the Medicaid population. An additional $2 billion by adults and children gaining private dental benefits through exchanges and employer plans is also expected.
Expansion of Medicare coverage for older adults needing dental treatment is not expected. Currently Medicare practically has a blanket exclusion to dentistry with the exception of services provided in a hospital in connection with an underlying medical condition, such as extraction of teeth to prepare jaw for radiation treatment, or an oral examination as part of a comprehensive workup prior to renal transplant surgery or heart valve replacement. Beginning in 2014, older adults may purchase coverage through an exchange or under a private plan. Private plans for over 65 seniors have been available for many years, as have Medicare supplement plans with dental provisions.
Additional information concerning state-by-state ACA policies and projections are available from the ADA.org website. States already known to have more extensive dental coverage under existing Medicaid plans are AK, CT, IA, NM, NY, NC, ND, OH, RI, and WI, and these plans are likely to continue or increase. Other states may or may not develop or increase adult coverage.
For example, in Colorado where I work in a private general practice, a new adult Medicaid dental benefit is set to begin in April of 2014. The benefit will amount to up to $1,000 in everyday dental benefits such as exams, cleanings, and scheduled work. This is a huge improvement over the limited emergency type coverage previously available. However, there are still many questions, such as what amount will be covered per service, if previously non-Medicaid providers might be required to accept all Medicaid patients, and what, if any, increases to general Medicaid fees might apply.
In additional news, the ADA is already making the 2014 CDT coding manual available. Treatment codes are going to be updated on an annual basis from now on and input from the profession for 2015 codes are now appropriate (up until Nov. 1, 2013). The 2014 manual has included codes for Caries Management by Risk Assessment (CAMBRA) for the first time and is expected to further address diagnostic concerns in this and future revisions.
Carol Tekavec RDH is the Director of Hygiene for McKenzie Management. Carol can improve your hygiene department in just one day of training “in your office.” Interested in knowing more about how to improve your hygiene department? Email firstname.lastname@example.org.
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