Proposed national oral health insurance changes could affect NC benefits


Author: Anne Bryce

This may not be a topic in everyday conversation, but it's important—especially when considering overall health.

Your mouth is where the digestive process begins. It is also a key part of the respiratory system.

These things may seem obvious to many people. So why, oral health care providers ask, is what’s in your mouth—your teeth and gums, first and foremost—seen as less important when it comes to insurance and other health care benefits?

In a letter earlier this month to Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, ADA leadership explained why it shouldn’t happen This situation.

The Jan. 4 letter was prompted by an announcement late last year that more adults could get dental coverage in the Affordable Care Act (ACA) marketplaces if proposed rule changes go into effect.

CMS proposes lifting a ban that prohibits states from including adult dental services as one of 10 essential health benefits in ACA-compliant plans and marketplace plans.

The change will take effect in 2025, but states will have the final say. Under the proposal, states would not be required to provide dental services but would no longer be prohibited from providing essential health care services for adults.

Pediatric dental services are considered an essential benefit. The same goes for primary care, substance abuse and ambulatory care services.

“We believe this proposal will incentivize countries to increase routine non-pediatric dental services,” the 414-page proposal states.

Under the proposed rule change, adding such services as an essential benefit would give states the ability to “work to improve adult oral health and overall health outcomes that are at risk in marginalized communities like people of color and low-income people.” The results are particularly low.”

“Lack of dental insurance remains one of the major barriers to accessing dental care, and this proposed policy will help alleviate that barrier.”

mouth and body

In recent years, oral surgeons, dentists, and hygienists have been working to dispel the notion that oral health and overall health are not inseparable.

“Untreated oral health conditions may increase the risk of other chronic diseases and complicate management,” the proposed rule change states. “For example, research shows that periodontal disease and tooth loss are closely related to heart health, and oral care can reduce heart disease. Risk of vascular disease, atrial fibrillation and heart failure.”

According to the federal government, further research shows that people receiving substance use disorder treatment adhere more consistently to their treatment plan if they receive comprehensive oral health care, both in the facility and after discharge.

The federal agency adds that having a healthy smile also improves employment prospects.

“About 30 percent of low-income adults in the United States and nearly 60 percent of Medicaid recipients without dental coverage say the appearance of their mouths and teeth limits their ability to interview for jobs,” the rule change materials state.

Medicaid Dental Benefits

North Carolina also made these points.

In December, as many as 600,000 people also became eligible for oral health benefits after they gained expanded Medicaid health care coverage.

The state's Medicaid program provides routine cleanings, oral health exams and other preventive services through a comprehensive oral health benefits program.

The problem is, only about 45% of North Carolina dentists accept Medicaid patients. Many of these dentists are not accepting new Medicaid beneficiaries, leaving coverage gaps across the state.

As they lobby for more dentists to consider treating more Medicaid recipients, oral health advocates say providing preventive care can keep people in extreme pain from infected gums and broken teeth out of the emergency room. This care may also benefit a person's mental health and financial viability by improving gum and dental health.

“The people of North Carolina deserve an oral health care system that contributes to their overall health,” Frank Courts, chairman of the North Carolina Dental Association's Oral Health and Prevention Committee, wrote in a letter published by Neuse News. “State leaders have Responsibility for finding ways to adequately fund dental care for Medicaid recipients. Achieving this goal will save the state money in the long run and lead to a healthier, more productive population.

incremental progress

It's unclear whether there would be widespread impacts in North Carolina if adult dental services became an essential health benefit in Affordable Care Act marketplace insurance plans.

This year, nearly one million North Carolina residents will receive health insurance under individual insurance plans in the Affordable Care Act marketplace. Others get coverage through their jobs or state and federal programs such as Medicaid or Medicare.

How do North Carolinians get health insurance?

  • From employer – 46.5%
  • Individual coverage – 7.5%
  • Medicaid – 18.6%
  • Medical insurance – 15.7%
  • No insurance – 9.4%
  • Military (VA, TRICARE) – 2.4%

— Source, KFF, 2022 data.

About 110 million Americans had private dental insurance in 2020, according to the Centers for Medicare and Medicaid Services. Nearly 91% of them receive dental benefits through their employer or an organization such as the American Association of Retired Persons (AARP), the federal agency added.

When essential health benefits were created in the early days of the Affordable Care Act, federal officials placed a strong emphasis on employer-provided benefits. Dental insurance plans are often offered by employers as an additional cost, so oral health care is often excluded from basic coverage in federal marketplace plans.

American Dental Association leaders emphasized the importance of designating essential oral care services in a letter to the federal government supporting changes to essential health benefits.

Their recommendations include diagnostic, preventive, emergency and restorative care. Additionally, ADA recommendations include oral and maxillofacial surgery, endodontic and root canal treatments, gum and oral tissue treatments, dentures and other restorations, and orthodontics.

Any such marketplace plan should allow dependent children to remain on the parent's plan until age 26.

The National Dental Association also requires consumer protections to cover plans sold on federal and state marketplace plans.

“The ADA will support stronger policies on reasonable assurances that individuals and small groups within and outside the marketplace provide adult dental benefits to consumers,” the letter states.

Health insurance has changed what is “necessary”

For North Carolina residents who receive Medicare, the program that covers seniors and many people with disabilities, the wait to get more dental coverage won't be that long.

The Biden administration announced late last year that it was changing Medicare payment policies to clarify the interpretation of “medically necessary dental services.”

Coverage has been expanded to include any dental or oral exam before organ transplant surgery and heart valve replacement surgery, according to KFF, a group that tracks health policy research.

This year, Medicare will cover radiation, chemotherapy and dental work needed after treatments related to head and neck cancer.

Even with these changes, coverage of dental services under Medicare remains very limited, according to KFF.

“While these rules modestly expand the types of dental services covered by Medicare, they do not represent a broad expansion of Medicare dental service coverage, such as coverage of routine preventive services including exams and X-rays, or a broader range of dental services. Coverage.

“Without expanded dental coverage under Medicare, Medicare recipients without other sources of comprehensive dental coverage will continue to face relatively high out-of-pocket costs, especially if they require extensive dental care unrelated to other coverage,” ” KFF concluded.

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