Dec. 11--Under new health reform laws that take effect Jan. 1, pediatric dental care must be part of your health insurance plan -- whether or not you have kids -- if you have an individual or small group policy and if that policy is an "off-exchange plan" -- meaning bought outside of Oklahoma's new federally-administered online marketplace.
If you buy an insurance plan through the exchange, it's up to you whether you buy pediatric dental coverage -- regardless of whether you have kids. But if you buy a stand-alone dental plan, the most you'll pay, excluding monthly premiums, is $700 per year per person. If you buy a medical plan with embedded pediatric dental coverage, your combined medical and dental out-of-pocket maximum, will be limited to no more than $6,350 per person annually.
Understanding and implementing the regulations under the Affordable Care Act are confusing enough without the pediatric dental mandate to chew on, some observers say. While providers and dental insurers cautiously support the increased emphasis on children's oral health, they worry parents and others will have a hard time making sense of them.
Employers in the small group market, or those who employ fewer than 50, are scrambling to make sure they're ACA-compliant by offering dental coverage, Oklahoma City employee benefit consultant Cher Bumps said.
"Employers don't have to change their plans and cover dental," Bumps said. "But they have to make the coverage available, and it's up to the employee whether or not they buy it."
Insurers are required to have "reasonable assurance" if someone waives dental coverage that they have the mandated pediatric dental coverage elsewhere, Bumps said. She said Blue Cross and Blue Shield of Oklahoma is having employees who waive dental coverage sign affidavits.
John Gladden, president and chief executive of Delta Dental of Oklahoma, believes that under the new mandate, children will be more likely to receive preventive and restorative care.
"And if more kids get to the dentist, that's super," Gladden said. Only about half of Oklahomans have dental insurance, and Delta Dental covers about half of those who do, or 800,000, he said.
"But the new mandate is so swishy and flexible that it might be difficult to manage," Gladden said.
Limit opens possible abuse
The potential difficulty comes because on-exchange, stand-alone plans are required to carry a maximum out-of-pocket limit of $700 per person per year. "Anything past that is paid at 100 percent, so the sky's the limit," he said. "And when there are no limits, there's an opportunity for abuse."
"Your dentist could tell you that you need $5,000 worth of work, and you could go out and buy insurance after he's told you that. It's like buying fire insurance after your house burns."
Meanwhile, the new laws can cause further conflict and confusion, he said, because the pediatric mandate covers only orthodontics or wisdom teeth removal that is "medically necessary," he said. Consumers, he said, mistakenly may think the dental plan they buy covers braces, or removal of their child's wisdom teeth versus only those teeth currently causing problems.
The pediatric dental mandate will be an actuarial experiment, Gladden said. "Only time will tell if people who have low utilization of services will generate enough premium to cover those with higher utilization," he said.
Exchange costs more
Because of the maximum out-of-pocket limit, dental insurance bought inside the exchange costs more than insurance bought outside the exchange or through employers, Gladden said. For example, policies bought on deltadentalok.org run from $25 to $40 per individual per month, Gladden said, while on-exchange rates are "coming in north of that," he said.
As of Friday, reports showed Delta Dental had 60 enrollees in its on-exchange plans, but the company could confirm only six of those, Gladden said. Aside from its own stand-alone plans, Delta Dental will be the administrator of the pediatric dental coverage embedded in the on-exchange health insurance plans of CommunityCare and GlobalHealth Inc., he said.
Tim Fagan, a pediatric dentist in Enid and president of the Oklahoma Dental Association, is excited about the prospect of more children with dental coverage. "But we'll have to wait and see how it all shakes out," Fagan said.
The American Dental Association estimates 8.7 million children could gain extensive dental benefits by 2018, but more than 3 million of that number is because of Medicaid expansion under the ACA and "Oklahoma, because it chose not to expand Medicaid, is losing out in that regard," Fagan said.
Moreover, because of the state's increase in per capita income, Oklahoma in October will receive tens of millions of dollars less for Medicaid, which will put existing pediatric dental services in "serious jeopardy," Fagan said. But Oklahoma Health Care Authority spokeswoman Jennie Melendez said Tuesday the agency so far isn't planning to cut services.
Meanwhile, Variety Care nonprofit community health clinic -- which serves some 60,000 uninsured, working poor on a sliding scale basis -- this week broke ground on an 8,000-square-foot, $4.3 million, expansion to its six-chair dental center at Straka Family Health Center in south Oklahoma City. Upon completion, the center will feature 21 chairs, with six focused on pediatric dental care.
"It was a wise decision by the ACA to involve oral health care early," Variety Care Chief Executive Lou Carmichael said. "So much of what we see in third-graders -- from decaying teeth to gum disease -- could be prevented with education and care, and save billions of dollars," Carmichael said.
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