Dental Benefits Unraveling

Dental Benefits Unraveling

Health care reform is due to bring significant changes to the payment and reimbursement of dental services, including little-noted — but not low-cost — orthodontia. Dental industry experts weigh in on the potential implications

So long, dental plan? But Lisa needs braces.

The American Association of Orthodontists says between 50% and 75% of the general population could benefit from some kind of orthodontic treatment. The majority of patients in the United States and Canada begin treatment between the ages of 9 and 14, but there has been a rise in adult treatment as well: from 1989 to 2010, the AAO says, the adult population of ortho patients is up 23%. The average cost of orthodontia (for either children or adults) tops $6,000 in America — no small fee, and one that makes dental insurance essential. However, without regulatory clarification, health care reform could disrupt coverage for millions of participants

Among the many unknowns that come with the implementation of the Patient Protection and Affordable Care Act is one that could hit consumers' right in the teeth: orthodontic reimbursement. Pediatric dental, says Evelyn Ireland, executive director at the National Association of Dental Plans, isn't going anywhere, but parents and others planning on braces should also brace for some cost-shifting.

"Orthodontia is one of the big coverage differences that are proposed to occur for pediatric dental," Ireland says. "Pediatric dental in the proposed rules is defined as any enrollee up to 19. So, the way [PPACA] is structured, pediatric dental is a benefit that is described as part of the essential health benefits that will be offered in the small group and individual market. Of course, the small group market includes exchanges."

Ireland says one of "the biggest changes" to dental coverage may come from the establishment of categories of orthodontic needs.

"Pediatric dental ... does not include cosmetic ortho, which is kind of problematic because there's not a definition of cosmetic ortho," she says. "The original definition said it would include medically necessary ortho; we've asked them to clarify."

Ireland points out that orthodontia "is not preventive care," and thus does not get much largesse from PPA-CA. This is despite the fact that orthodontists say straightened teeth can lead to increased health benefits running the gamut from reduced plaque to improved digestion. Many experts consider the mouth a physiological gateway to overall good health.

Still, for the time being, fixing crooked teeth is medical treatment or cosmetic improvement, not preventive due diligence.

So, how many braces, headgears and mouth guards would qualify for financial assistance? Only about 30% of them, Ireland says.

"If 70% of the people who currently could get reimbursement for orthodontia don't get it — that'd be a big shift in coverage," Ireland says. "Birth to age 20, 18% to 19% of all children have an orthodontic procedure, so roughly one-third of those would continue to be covered. All the rest of them would not have any coverage under the essential health benefits package.

"Now it's anticipated that on exchanges and in the private market, too, there will be various wrap options where you can add on coverage for the family, for adults, for older children — there might be some orthodontic coverage in that. The other big change in the way [PPACA] is structured is there's no annual or lifetime maximum ... and that also applies to pediatric dental."


Pam Paladin, marketing and member/consumer relations manager for the AAO, says, as of 2010, 60% of all new orthodontia patients had dental coverage that included orthodontic benefits. Twenty-two percent of them, or less than 1.1 million people, were adults.

"I know there are wide variations [in coverage]," Paladin says, adding that the more than 9,000 practicing orthodontists in the United States await further guidance via Health and Human Services regulations.

Looking ahead to 2014, Ireland says, "the way the coverage works in terms of reimbursement remains to be seen," but, "if it's similar to a policy today, ortho is around 50% covered." With the average cost of an orthodontia claim at around $6,250 nationwide, there's a big range of how that bill could get diced up.

"Dental plans in exchanges are being asked to have a lower out-of-pocket maximum, and that's probably going to be around $1,000. So the consumer could pay a $50 deductible and have the $6,200 left, and then it would be 50% of that, which would be beyond the reasonable out-of-pocket limit, so actually the plan would pay more like $5,000," Ireland says. "[Consumers] could end up paying anywhere from $4,000 or $5,000 to only paying $1,000. That's a huge difference."

Any cost-shifting, Ireland says, messes with a fragile system. Dental coverage in general could suffer, and "the deterioration of oral care" would follow as those with dental insurance go to the dentist 2.5 times more often than those without.

"Most employers are going to continue to offer dental as a supplemental policy, something the consumers can add on, but they might reduce their contribution toward it or make it a totally voluntary program," Ireland says. "I don't think the vast majority of employers would just drop the coverage, but they could do enough cost-shifting to the consumer that it could significantly impact the enrollment rates. Right now ... [about] 57% of the population [has] coverage, except for a dip in 2010, but that dip, because of the economy, was pretty significant. It was about a 10-million person dip, and we could see that kind of dip again."

The American Dental Association says that the effects of PPACA "on health care in general and on dentistry in particular remains uncertain at this stage" and it notes that "dental care for adults is not included" in the essential benefit package. Still, the ADA says children's coverage should grow.

"It is estimated that 3 million children will gain dental benefits through the health insurance exchanges by 2018, or roughly a 5% increase over the current number of children with private dental benefits," the ADA says, adding that "more than 99% of dental practices have 50 or fewer employees" and thus won't be required to offer coverage themselves.

With so many unknowns, Ireland says, more information from HHS is needed as soon as possible. We may not be exactly sure how we're going to get there, she says, but the goal is improved and more coverage, not less.

Countries with socialized medicine aren't exactly famous for their beautiful smiles. We don't want things trending that way, right?

Ireland laughs. "I'd never thought of it that way," she says.



The Department of Health and Human Services has published proposed regulations defining the "essential health benefits" that must be included in insurance plans in these markets. These regulations address cost-sharing limits and the valuation of coverage.

PPACA defines "essential health benefits" by specifying 10 categories of benefits that must be covered by all health insurance plans offered through an exchange:

• Ambulatory patient services

• Emergency services

• Hospitalization

• Maternity and newborn care

• Mental health and substance abuse disorder services

• Prescription drugs

• Rehabilitative and habilitative services and devices

• Laboratory services

• Preventive and wellness services and chronic disease management

• Pediatric services, including oral and vision care

The new regulations extend the rules to all non-grandfathered plans offered in the individual and small group (generally less than 100 employees) markets and define the expenses that must be covered within the 10 categories. The regulations establish a list of permissible benchmark plans.

Each state is required to designate an EHB benchmark plan from that list to serve as the standard for benefits in those categories. If the state does not select a benchmark plan, the benchmark plan will be determined in accordance with default rules established by HHS.

If the chosen plan does not cover all of the required EHB categories, the state will be required to supplement the benefits in accordance with specified rules to establish a benchmark for coverage in that category. Plans may substitute benefits within a category for those established in the benchmark plan provided the substitution is at least actuarially equivalent. The regulations address a number of more specific issues with respect to EHB:

• Requiring plans to cover at least one prescription drug in each category or class in a specified list. Plans must also cover at least the same number of drugs in each category and class as the EHB-benchmark plan.

• Allowing states to require an exchange plan to cover benefits in addition to the EHB, but the cost of any of these additional benefits mandated after Dec. 31, 2011, must be defrayed by the state.

• Mandating issuers that offer coverage on the exchange must offer the same EHB package in policies offered on the individual or small group market outside the exchange.

In addition, the regulations provide that the annual limit on cost-sharing (including all deductibles, copayments, coinsurance and similar employee charges applicable to EHB) will be set at the annual high deductible health plan limit for out-of-pocket expenses. For 2013, this limit will be $6,250 for self-only coverage and $12,500 for other tiers of coverage.

The regulations also adopt a standard methodology for determining the level of coverage under a health plan: bronze (which covers 60% of the actuarial value of expenses), silver (70%), gold (80%) or platinum (90%). The proposed rules allow for small variations in these levels.

Source: EBN Legal Alert/ TrisTan Lejeune