Will Dentists Find Dealing with Insurance Exchanges a Disaster?

Will Dentists Find Dealing with Insurance Exchanges a Disaster?As of the first of this year, dentists and health care providers have been closely monitoring the changes being implemented due to the Affordable Care Act.

Under the Act, as of January 1 all U.S. states were supposed to notify the U.S. Department of Health and Human Services if they are creating online exchanges for the October 1, 2013, deadline when Exchanges are to be made available to anyone without insurance and small businesses throughout the U.S.

The Exchanges will allow the general public to go online to compare health insurance plans and buy health insurance from the state-operated health Exchanges, as well as insurance plans being offered by the federal government.

Stand-alone dental insurance plans and pediatric dental coverage will be offered by these Exchanges, but it is still not known if adult dental coverage will be offered separately from health insurance on these Exchanges and what the requirements for dental coverage will be within the Exchanges themselves.

The New York Times reported last week that Health and Human Services Secretary Kathleen Sebelius will extend the deadline for any states that expressed interest in creating their own exchanges or overseeing insurance sold through a federal exchange.

Thus far, only 18 states and the District of Columbia intend to run their own health insurance Exchange. In the states that decide not to set up their own Exchange the federal government will implement federal health insurance Exchanges.

According to the U.S. Department of Health and Human Services, the Affordable Care Act will ensure that Americans will have access to quality, affordable health insurance.

To achieve this goal, the law ensures health plans offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges, will offer a comprehensive package of items and services, known as “Essential Health Benefits.”

Essential Health Benefits must include items and services within at least the following 10 categories:

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management, and

10. Pediatric services, including oral health and vision care

States will have the flexibility to select a benchmark plan for insurance coverage that reflects the scope of services offered by a “typical employer plan.” This approach is intended to give states the flexibility to select a benchmark plan that will best meet the health insurance needs of their citizens.

The health insurance plans must offer benefits that are “substantially equal” to the benchmark plan selected by the state and modified as necessary to reflect the 10 coverage categories.

Health insurance plans will have flexibility to adjust benefits, including both the specific services covered and any quantitative limits, provided they continue to offer coverage for all 10 statutory essential health benefit categories listed above and the coverage has the same value.

Dentists are deeply concerned how these changes will impact their dental practice.

Dentists who in the past have accepted a percentage of Medicaid dental patients understand all too well what it is like to deal with a government-run dental care benefit provider.

Medicaid dental care reimbursements have always been low, even before Medicaid began eliminating adult dental care from its benefit plan. Private employer dental insurance plans have offered dentists more new dental patients with better reimbursement rates.

More than 5 million children will become eligible for dental coverage under the Affordable Care Act and pediatric dentists are concerned the insurance changes implemented by the Act could result in fewer insurance companies offering dental health plans to families, thus leaving dental practices treating children with a state or government-based dental benefit plan.

The National Association of Dental Plans have made dentists aware of the rule that families who buy dental coverage on an Exchange may be subject to an annual out-of-pocket cost-sharing limit (possibly up to $1,000) for dental care.

This could have a very real impact on many dental practices’ bottom line.

The PricewaterhouseCoopers report “Patients or Paperwork” revealed that the Medicare and Medicaid “rules and instructions” are more than 130,000 pages (three times larger than the IRS code and its associated regulations), and “medical records must be reviewed by at least four people to ensure compliance” with Medicare program requirements.

No wonder dentists are concerned about federally-run health Exchanges.

The only thing certain about the Affordable Care Act is that its implementation will bring changes to dental care, dentists and their dental practices.

What are your thoughts on the future of dentistry and the Affordable Care Act?

To read more about the Essential Health Benefits see: HHS Informational Bulletin

About Jim Du Molin

+Jim Du Molin is a leading Internet marketing expert for dentists in North America. He has helped hundreds of doctors make more money in their practices using his proven Internet marketing techniques.

  • CA Dentist

    Do we have to work for Fed. plan?  Do we have to accept these dental plans from the Act?
    How will 4 people review and agree on what is acceptable for care or not to care on the Medical record?   At the moment in CA, to get reimburse for a filling from Denti-Cal , one must send a claim with explanation and with a picture and /or a copy of x-ray supporting the treatment!!!
    I cannot imagine what kind of record we have to write to protect ourselves and become acceptable to the 4 People!!!!!!

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