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04/18/2014

What dentists need to know about Covered CA benefits


As of March 31, the first open enrollment period in health care reform implementation through the California Health Benefit Exchange’s individual market (Covered California) is in the books. So, it is now time to start thinking about what happens next for the people who have new dental policies and what treating these patient will mean for dentists.     

While Covered California has not yet released final data on how many pediatric dental policies were ultimately sold prior to March 31, we do know the numbers are far less than originally expected. As of the end of February – one month shy of the end of open enrollment – only 20,317 policies from the available standalone dental plans had been sold. This represents only 36 percent of the total number of full-service health policies sold for children through Covered California. The vast majority of pediatric policies sold (36,218) were medical-only policies. 

While the number of dental policies sold is less than expected, there are still more than 20,000 California children who did not have dental coverage before who are likely soon to be seeking dental care. Their new coverage could be from any of the five dental companies selling plans in the Exchange – Anthem, Delta Dental, Liberty, Blue Shield or Premier Access. 

If and when a patient comes into your office with Covered California dental coverage (or they may call it “Obamacare”), it is important to remember that what they really have is private dental insurance offered through one of these standalone dental plans. Policies purchased may be DHMOs, DPPOs or EPOs.   Despite the somewhat unique and new way they purchased the benefit, these plans operate functionally just like any other commercial dental plan.   

If a dentist is not already part of the dental network for this plan, the office should find out what the reimbursement rates would be for services provided by an out-of-network provider. By design, out-of-network provider reimbursements are exceptionally limited through these plans. 

If a dentist is interested in becoming part of an Exchange plan’s network, the office should ask the plan for the specific contractual terms of its Exchange product, including the specific fee schedule used for reimbursement under this product and the number of new patients the office should expect to see with this plan. It should not be assumed that the dental plan would reimburse network providers at the same rate as for services provided under other policies offered by that plan. 

While these Exchange plans function like other commercial insurance products, these are new policies likely sold to new patients who may not have a great deal of experience with dental coverage and may not have focused on the benefits included in the policy when they purchased it. It will be important for dental offices to communicate directly and clearly with the patient as well as the patient’s plan before treatment begins. 

For more information on the pediatric dental coverage offered by the plans through Covered California, you can access the pediatric dental booklet.

CDA is an ongoing resource to members who have questions about the health care reform law, its implementation in California, and how it may impact dentists and the profession.

For more information, please contact me at nicette.short@cda.org