ACA leaves gap be­tween den­tal, med­i­cal cov­er­age

Modern Healthcare - - NEWS - By Bob Her­man

Even though teeth and gums are just as much a part of the hu­man body as kid­neys, they are cov­ered very dif­fer­ently by the Amer­i­can health in­surance sys­tem.

As part of the health­care re­form law, Congress in­cluded a few pro­vi­sions that may boost ac­cess to den­tal care. But the law does not in­clude com­pre­hen­sive cov­er­age, and mil­lions of Americans still lack ac­cess to a den­tist. How­ever, that’s not what a con­gres­sional panel was in­ter­ested in last week when its mem­bers grilled CMS Ad­min­is­tra­tor Mar­i­lyn Taven­ner about how 400,000 den­tal plan en­rollees got in­cluded in the 2014 Oba­macare en­roll­ment tally.

The re­form law man­dated pe­di­atric den­tal ser­vices as one of its 10 es­sen­tial health ben­e­fits, but adult den­tal ser­vices were ex­cluded. All health plans must cover oral health risk as­sess­ments on a first-dol­lar ba­sis for chil­dren up to age 10. The law also al­lowed states to ex­pand Med­i­caid, which will ex­tend den­tal ben­e­fits to more low­in­come adults.

But large cov­er­age gaps re­main for those adults who don’t qual­ify for Med­i­caid. “It re­ally only helped adults in a min­i­mal way,” said Max­ine Fein­berg, pres­i­dent of the Amer­i­can Den­tal As­so­ci­a­tion.

About 187 mil­lion Americans have some form of den­tal in­surance, ac­cord­ing to the Na­tional As­so­ci­a­tion of Den­tal Plans. Cov­er­age is mainly pro­vided through em­ployer plans, Med­i­caid and the Chil­dren’s Health In­surance Pro­gram. That leaves about 130 mil­lion peo­ple who have to pay for their den­tal care com­pletely out of pocket or rely on sup­ple­men­tal den­tal poli­cies. Tra­di­tional Medi­care does not cover den­tal care un­less it’s an emer­gency pro­ce­dure per­formed dur­ing a hos­pi­tal stay.

Lack of cov­er­age, high costs and lack of ac­cess to den­tal providers can be fa­tal. In 2011, Kyle Wil­lis, 24, died in Ohio after a wis­dom tooth in­fec­tion forced him to go to the emer­gency depart­ment. Wil­lis had no in­surance and couldn’t af­ford an­tibi­otics.

Ul­ti­mately, the health­care re­form law is ex­pected to bring some kind of den­tal cov­er­age to 8.7 mil­lion chil­dren and 17.7 mil­lion adults by 2018, ac­cord­ing to a Mil­li­man anal­y­sis. Most of those peo­ple will get cov­er­age through Med­i­caid ex­pan­sion, although Med­i­caid den­tal ben­e­fits for adults vary widely by state. Of the states ex­pand­ing Med­i­caid, only nine pro­vide “ex­ten­sive” adult den­tal ben­e­fits. And only one-third of prac­tic­ing den­tists ac­cept Med­i­caid, an ADA study found.

Colin Reusch, a se­nior pol­icy an­a­lyst at the Chil­dren’s Den­tal Health Project, said he hopes new value-based pay­ment and de­liv­ery mod­els will in­crease the fo­cus on oral health and its con­nec­tion to over­all health.

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