Advocates Protest Affordable Care Act Dental Regulations

Laird Harrison

July 11, 2013

Multiple advocacy groups are protesting rulings that could weaken the oral health provisions of the Affordable Care Act.

In one letter, a coalition including most of the largest trade and advocacy groups for children's health is calling on the US Treasury Department to expand subsidies for dental benefits.

In another letter, 9 US senators call for lower limits on the out-of-pocket charges dental plans can charge.

Congress and the administration have worked separately to pare away aspects of the act advocates were hoping would substantially improve Americans' oral health.

For example, the act allocated funds for prevention, training, research, and public education about oral health, but Congress has not appropriated these funds. The act also provided for demonstration projects for alternative providers, such as dental therapists, but Congress has not released these funds either. The Department of Health and Human Services (HHS) has ruled both that individuals are not required to purchase pediatric dental benefits in some instances where they are required to purchase the other essential benefits listed in the act, and that limits insurers can charge on out-of-pocket costs for medical plans do not apply to separate dental plans. In addition, the Internal Revenue Service (IRS) has ruled that individuals cannot get government subsidies to purchase stand-alone dental benefits.

Other rulings stipulate that dental benefits offered through the act must be more comprehensive than many plans that are on the market now. However, that could make the plans expensive and cause some adults who have benefits now to drop them to pay for their children's plans, according to an analysis by the National Association of Dental Plans (NADP).

To understand how all this happened, it is useful to look at the way the Affordable Care Act was intended to work. The law aims to expand healthcare coverage through 3 main provisions: It requires health insurance companies to accept almost everyone, regardless of how sick they are; it requires almost everyone to have health coverage or pay a special tax; and it provides subsidies to people who cannot afford coverage on their own.

But oral care is half in and half out of this formula.

In the first place, the law does not require everyone to have dental coverage. The individual mandate, the most controversial part of the law, says everyone should have "minimum essential coverage."

The act lists 10 "essential benefits," among them "pediatric services, including oral and vision care." So from the start, the act never envisioned a way to expand dental benefits for adults, only children.

A "Setback"

In addition, different rules apply to these benefits depending on whether they are sold to big companies, small companies (with 50 employees or fewer), or individuals; whether they are sold inside or outside the exchanges that the act sets up; and whether the dental benefits are sold separately (as most are now) or bundled into medical insurance plans.

The essential benefits requirement never applied to large employers. Now the HHS has ruled that individuals and small employers shopping inside the exchanges do not have to buy pediatric dental benefits either, if dental benefits are not bundled into medical insurance plans. Only those small companies and individuals shopping outside the exchanges will be required to get the benefits.

The ruling surprised many oral health advocates. "We certainly see it as a setback," Colin Reusch, policy analyst at the Children's Dental Health Project (CDHP), told Medscape Medical News.

Some states are taking it on themselves to mandate pediatric dental benefits inside the exchanges, even though the federal government does not require this. Others, including California, are not requiring anyone to purchase the pediatric dental benefits offered in their exchange.

A second HHS ruling has also proved controversial. It sets separate limits on out-of-pocket expenses families must pay for their medical and stand-alone dental insurance. "That was not Congressional intent," Sue Walitsky, a spokesperson for Sen. Ben Cardin, D-MD, told Medscape Medical News.

Sen. Cardin and 8 other senators, along with the CDHP, argue that the same overall limit should apply to all out-of-pocket expenses. This would make the policies more affordable, they argue.

At this time, the HHS has set a limit of $700 per child for out-of-pocket dental expenses. The NADP is pushing for a $1000 limit, arguing that setting the limit at $700 will force insurers either to charge more for their policies or reduce their reimbursement for routine services.

The HHS declined a request for an interview, instead providing a general description of dental benefits in the Affordable Care Act.

Dental Plans not Subsidized

Nearly all the advocacy groups are united in opposing another ruling. The law offers subsidies for healthcare coverage in the form of a tax credit for families for up to 400% of the federal poverty level.

How much subsidy a family gets is largely determined by its ability to pay for the cost of a "silver" healthcare plan, one with a medium range of benefits. The IRS has ruled that it will not count any premiums paid for stand-alone dental plans as part of the cost of such a silver plan.

The NADP and CDHP, along with the American Dental Association and many other groups, are united in calling for the IRS to include anything a family is paying for stand-alone dental plans when determining subsidies.

The IRS and Treasury Department declined requests for an interview. The Treasury Department issued a statement saying it was reviewing the question.

In the meantime, as a result of these rulings, advocates are scaling back their estimates of how many new patients might get dental benefits.

"The intention was to increase the number of people with coverage, but the system put in place won't necessarily do that," Evelyn Ireland, executive director of the NADP, told Medscape Medical News.

The number of adults with coverage has been declining, while the number of children with coverage has been increasing, mostly through Medicaid and the Children's Health Insurance Program. The new law looks likely to accelerate that trend, she said.

The American Dental Association published an estimate indicating that a maximum of 8.7 million children and 17.8 million adults would gain coverage by 2018, mostly through the expansion of Medicaid. But the association also acknowledged that the recent rulings could lower those numbers and pointed out that in many cases, the adults would gain only minimal coverage through Medicaid.

The NADP estimates that as many as 11 million adults could drop their coverage to afford benefits for their children.

As for the prevention, training, and education programs not funded by Congress, the advocacy groups appear to be devoting little of their attention to these issues for now.

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