Second Opinion: Questions we should be asking insurance companies -- Part 1

By Jason P. Hirsch, DMD, MPH, DrBicuspid.com contributing writer

April 20, 2015 -- I write this article to address the confusion surrounding the Patient Protection and Affordable Care Act (ACA) and dentistry. A recent article on DrBicuspid.com with quotes from a Guardian Life Insurance executive referred to the ACA and the essential health benefits offered through HealthCare.gov exchanges as a reason for dentists to join their network.

I would like to examine the law as it pertains to the essential health benefits, specifically pediatric dental coverage/services. There is confusion about the mandates of the ACA. One of those mandates was incorrectly explained by the Guardian executive, possibly to confuse dentists into signing up for some windfall that might be completely bogus.

Jason P. Hirsch, DMD, MPH
Jason P. Hirsch, DMD, MPH.

Pediatric dental services must be offered to a customer who is purchasing medical insurance through a government exchange. Let's be clear, the customer shopping for family medical insurance only has to be offered pediatric dental insurance, they do not have to purchase it.

My guess is that customers would be better off without the dental rider unless it was very clear and devised by an independent preventive dental organization. I am suspicious of the sales tactics as well because of the steep increase year over year of medical plans with embedded dental plans being sold.

Here is the language from HealthCare.gov:

Dental coverage for children is an essential health benefit. This means if you're getting health coverage for someone 18 or younger, dental coverage must be available for your child as part of a health plan or as a standalone plan. Note: While dental coverage for children must be available to you, you don't have to buy it."

Here is a quote from the executive at Guardian, Marcia Vannuccini, in the DrBicuspid.com article.

"The overall individual dental market will expand, for a few reasons," Vannuccini said. "One of the reasons that we think the increase will happen is that the essential health benefits [of the ACA] require the inclusion of pediatric dental benefits. This inclusion has definitely raised the awareness of the need for dental care. We see this as the purchase of pediatric plans by parents for their children."

Are customers seeing the law as it is, or are they pushed into plans because the subsidy increases as more riders are attached? Are shoppers of insurance being told dental is not a mandate and there is no penalty for not having pediatric dental coverage? Are the salespeople pushing these extra components onto people because they are being reassured that the government will pay for it?

“It's important for dentists to understand what is being sold into the marketplace.”

Let's face it, as most professionals have a hard time with the lexicon of health insurance, it must be difficult for nonmedical/dental individuals to buy these plans from pushy salespeople earning commissions. Do people really know what they are buying?

It's important for dentists to understand what is being sold into the marketplace, as we will bear the brunt of the customer's feelings and the payment, or lack thereof, if we sign up to participate with these insurance companies.

I would like the Guardian executive to tell us the exact terms of their plans regarding reimbursement for preventive services:

  • What are the essential health benefits for pediatric dentistry?
  • Define these terms for us, since the government couldn't!
  • What are people getting for prevention?
  • Is it mandated that customers receive a minimum of two exams and two fluoride treatments per year at no additional expense past the premium for all plans sold?
  • Why are there 300 variations of preventive dental plans for sale on the exchange -- why confuse people?
  • Why do some plans have to reach a deductible threshold before dental benefits kick in, including prevention?
  • Are those really dental insurance plans when there is such a high requirement for first dollar coverage?
  • Why is there a bundled plan and an embedded plan?
  • Some of the most affordable medical plans have medical deductibles of $5,000. Are preventive dental services part of the included medical preventive services such as immunizations that are covered at 100%? No dental services are included on this list of pediatric medical services covered at 100%.

In part 2, Dr. Hirsch will address the patient and customer service aspects of these plans.

Jason P. Hirsch, DMD, MPH, is a pediatric dentist and public health specialist. He has been in practice in South Florida since 2002 and is currently building a new state-of-the-art medical management of caries and evidence-based orthodontic practice in Boca Raton, FL.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.


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