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PPACA: Dental Plans Weigh in on Essential Benefits

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Designers of the new “essential health benefits” (EHB) package should make sure that consumers have the ability to compare dental plans and buy dental coverage separately from medical coverage.

Dr. William Kohn, a representative of the Delta Dental Plans Association, Oak Brook, Ill., makes that argument in testimony presented to the U.S. Department of Health and Human Services (HHS).

HHS is now conducting regional listening meetings to get information and opinions regulators will use as they are creating the EHB.

The Patient Protection and Affordable Care Act of 2010 (PPACA) calls for HHS to define an EHB package.

If PPACA takes effect as written and works as drafters expect, individuals and small employers will be able to use new federal subsidies to buy health coverage through a new system of health insurance distribution exchanges starting in 2014. Plan managers will have to help consumers and others compare plan costs, on and off the exchanges, by stating what percentage of the actuarial value of the EHB package that each major medical plan sold covers.

A bottom-level “bronze” plan must cover 60% of the actuarial value of the EHB package, and a top-level “platinum” plan must cover 90% of the actuarial value of the EHB package.

PPACA requires the EHB package to include dental benefits for children.

Kohn, a former director of the Division of Oral Health at the Centers for Disease Control and Prevention (CDC), is now a vice president at Delta Dental, an association that represents a national system of large, nonprofit dental plans. The plans provide dental coverage for 56 million people, including 18 million children.

Kohn notes in a written version of testimony delivered at an HHS meeting in October that scientists are finding evidence that problems with oral health can hurt an individual’s overall physical health.

“Fortunately, dental disease is also highly preventable, and cost-effective, science-based preventive therapies exist to virtually eliminate dental disease if applied at the right time, at the right frequency, and to the right children,” Kohn says in the written testimony.

CDC figures show that just 20% of the children ages 2 to 19 get 80% of all the cavities that children get, and many of the children who get the cavities are low-income children who lack regular access to dental coverage and dental care, Kohn says.

“Studies have also shown that children with dental benefit coverage are far more likely to receive professional dental care and necessary preventive and restorative services,” Kohn says.

PPACA could have a big effect on improving the oral health services those children get, Kohn says.

Some groups have suggested that the only oral health benefits in the PPACA EHB package should be diagnostic and preventive care services, Kohn says.

“Given the large amount of untreated disease that currently exists in children we believe this would be a mistake,” Kohn says.

HHS should be careful about expanding the EHB package to includes services not clearly required by PPACA, but the federal Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA) does require children’s plans to over “services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions,” Kohn says.

“This captures the essence of what this essential benefit should look like,” Kohn says.

But HHS should probably be conservative about requiring coverage for more expensive, more questionable services such as orthodontia and wisdom tooth extractions, Kohn says.

“Orthodontia is rarely medically necessary,” Kohn says. “When orthodontics is covered on a typical commercial plan it is often a limited rider with lifetime limits applied. Depending upon what age the essential dental benefit is set at, the extraction of third molars (wisdom teeth) could also be an extremely costly add-on, unless strict guidelines for medical necessity are established (past age 18 third molars become a major cost issue). Inclusion of such procedures that are often desired by the public could make an ‘essential’ pediatric benefit premium unaffordable.”

The Delta Dental Plans Association believes it’s important “that stand-alone dental plans are separately offered and priced from the medical policy,” Kohn says. “A small minority of medical plans whose dental policies are embedded together in one integrated policy are opposing separate offer and pricing of medical and dental options. Without this transparency consumers will not be able to see what they are truly paying for their dental benefit within the medical plan. A level playing field needs to be maintained to allow consumers to continue the ability they currently have in the private market today that allows them to compare, cost, and choose the oral health care that will most effectively meet their needs.”


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