What dentists need to know about ACA

As of Jan. 1, 2014, many of the major reforms created by the Affordable Care Act (ACA) are in place. While the law is lengthy and has many complicated provisions, there are four basic concepts implemented by the law: providing private and public health insurance reforms and patient protections; allowing states to expand Medicaid coverage; requiring U.S. citizens to have health insurance coverage or pay a penalty; and creating marketplaces for health and pediatric dental insurance coverage. 

Patient Protections

The patient protections for adults and children included in the law prohibit insurance companies from denying coverage for people with pre-existing conditions, prohibit lifetime and annual dollar limits on coverage, institute fraud and accountability efforts, and require all health plans to offer 10 essential health benefits, including pediatric dental care. 

Another patient protection that is already in place for health plans is a medical loss ratio. This ACA provision requires health plans to spend at least 80-85 percent of the premium dollars on the medical care of their policyholders. Dental plans are currently not subject to the medical loss ratio requirement, but CDA is sponsoring legislation to apply this important patient protection to dental plans.  This will ensure that a larger portion of patient premiums are appropriated directly to dental care and would limit the amount dental plans can use for administrative costs (i.e., executive salaries, overhead and marketing) and profits. If a dental plan failed to achieve the minimum standard, the bill would require the plan to reimburse policyholders for its excess spending. This CDA-sponsored bill will be under consideration during the 2014 legislative session. 

Medicaid Expansion

The law allows states to choose to expand access to Medicaid insurance coverage.  Beginning in January 2014, California will expand Medicaid eligibility to all citizens who earn an income of 138 percent of the federal poverty level, which is equivalent to less than $15,000 a year. This change is expected to cover another 2 million low-income Californians without children. The federal government will pick up 100 percent of the costs for this expansion in 2014 through 2016, phasing down to 90 percent in 2020 and beyond.

As a result of the legislative budget process in 2013, dental services for adults will be added back into the Medi-Cal program beginning in May 2014 for the traditional Medi-Cal population, as well as the expansion population. That will mean an additional 3 to 4 million adults will receive dental benefits through that program. Also in 2013, 900,000 children who were enrolled in the Healthy Families program were transferred into Medi-Cal. For dental care, most are now accessing coverage through the fee-for-service Denti-Cal program.  

With these changes in the program, by early 2014 approximately 10 million Californians’ dental benefits will be provided by the Medi-Cal program.

Covered California

Along with the requirement that every citizen have health care coverage, the law allows states to develop their own insurance marketplaces. While many states are relying on the federal online marketplace that was plagued with issues at its rollout, California created its own online marketplace. While Covered California had similar troubles with its technology in the first few days, it has improved its functionality more quickly than the federal site. In California, according to Covered California, as of Nov. 30, more than 400,000 applications for insurance coverage are in the process of being completed through Covered California. This is still just a fraction of the number of purchasers that Covered California had expected to buy medical and pediatric dental coverage during this open enrollment period (Oct. 1-March 31). 

Pediatric Dental

CDA’s advocacy has made the online marketplace one that allows for robust competition among standalone dental plans and ensures that families have options in the types of products they can purchase, including at least one dental PPO option in each county. However, the implementation of the dental benefit here in California is still plagued with many problems.

Significant concerns have been raised with how the pediatric dental essential health benefit is being presented and sold through Covered California. In particular, the initial structure of the online marketplace made it difficult for families to find and purchase the pediatric dental benefit, and there have been reports that Covered California staff are not always equipped to provide the appropriate assistance families need to make informed choices regarding their dental coverage options. 

CDA has provided feedback to Covered California on the short- and longer-term fixes that need to be made to the website to ensure that families who want to buy the dental coverage through the portal can do so efficiently. Furthermore, CDA is working with Covered California staff to identify additional training that needs to be provided to the enrollment staff to help them better support families in accessing the dental benefits that are available to them. 

CDA’s Work

CDA remains actively engaged in all of the ACA implementation efforts, advocating on members’ behalf with the Legislature, administration, Covered California, regulators and the federal government. CDA is a resource to members interested in finding out more about the new law and how it may impact dentists and the patients they serve. 

For more information, please contact CDA’s Manager of Legislative Affairs Nicette Short at nicette.short@cda.org or 916.554.4970.