State Health Exchanges: A Federal Perspective
Special to the WSDA News from Jon Holtzee, Director, State Government Affairs at American Dental Association
With the enactment of the Patient Protection and Affordable Care Act (PACA) on March 23, 2010, many questions have been asked and many remain on how the state health exchanges which are required to take effect on January 1, 2014 will impact the accessibility and delivery of dental care in our country. While the answer will vary, depending on the nature of the exchange in each state, there are some things that are certain:
• While the Supreme Court considers the case, work will continue on exchange development;
• States may create discrete individual exchanges and small business exchange or create one unified system;
• Those purchasing through the exchange can do so through the web, by phone or through an insurance agent;
• The only dental benefit required is what’s called the “Pediatric Essential Oral Health Benefit” for those children whose coverage is purchased through the exchange. With the recent announcement by the feds that instead of establishing a national benchmark for that benefit, they will instead permit states to choose between a variety of approved benchmarks. It has become vital for constituent societies to become vocal advocates to be sure the best option is selected for that state;
• If a state declines to submit an exchange plan for approval to Health & Human Services (HHS) by January 1, 2013 for activation on January 1, 2014, the federal government will establish the exchange in that state;
• That despite these deadlines, the federal process for rulemaking and guidance to the states will most likely continue to be painfully slow;
• With over 75 percent of dental coverage being family coverage, requiring only a pediatric benefit may change the dental benefit design and market for those in the exchange; and
• The law requires that stand-alone dental plans be allowed as qualified plans within the exchange in addition to having a dental rider as an option to a medical plan.
A primary concern in the development of state exchanges is ensuring fair and robust competition among various plans offering dental benefits, and providing a variety of plan models within the exchange. Clearly an exchange that only offered a capitated benefit plan may have a difficult time creating a network of participating dentists to provide care to their enrollees. An example of these difficulties is highlighted by the existing exchange in Massachusetts, where a 2009 study funded by Blue Cross Blue Shield of Massachusetts found that access to dentists continued to be problematic. Only a limited number of providers are willing to accept the Dental HMO offered by Doral, which is the dental vendor for both Mass Health (the Massachusetts Medicaid & CHIP program) and three of the four Commonwealth Care (exchange) plans.
Additionally, we must work to make sure that decades of advancement in the regulation of health and dental benefits with enactment of prompt payment laws, non-covered service laws, required coordination of benefit with medical plans for procedures like hospital-based general anesthesia, and assignment of benefit laws are not rolled back within exchange offerings. Existing consumer protections governing dental benefits must be maintained within the exchange.
While the law requires that plan information be presented to consumers in the exchange with understandable language, it is critical that patients be able to completely understand how various dental coverages differ within the exchange. While one plan may be a major medical plan with an added dental benefit, other plans offered may be stand-alone medical plans and stand-alone dental plans. Without specific comparative information on dental benefits, costs, deductibles, co-pays, provider panels, etc. being spelled out in an “apples to apples” comparison by the major medical plan with a dental add-on, purchasers will not have the ability to make a truly informed decision about which plan will be best for them. Further, to ensure robust options and competitions, all medical plans that offer an embedded dental benefit should also be required to offer a similar medical only policy without a dental benefit so that purchasers have real options to make a variety of choices with their decisions.
Since the only required dental benefit within the exchanges will be the pediatric benefit, it is essential that the exchanges offer the option for the purchase of adult coverage (as an added expense), or a unified family dental plan. To ignore the purchasing patterns that currently exist for dental benefits may have very undesired consequences as the exchanges develop. (75 percent of dental plans today are sold as family plans)
The entire issue of exchange development is extremely dense and complex. That’s why the ADA has retained a number of experts from across the nation to advise both the national association and the state associations on the development and implementation of the new state health exchanges. While any article on the subject could go on indefinitely, I’ll close with what may be the most important recommendation any state dental association may make to their respective state exchange board. Given the broad differences between the delivery of medical care and dental care, given the vast differences between the design of medical plans and dental plans, and given the lack of knowledge most health administrators have about dental delivery, it is imperative for the Exchange Board to create a dedicated Dental Committee to develop and review the design and recommendations within the exchanges impacting dental care. That committee should be comprised of those with the most detailed knowledge of dental care and dental plans including the dental association, dental carriers and others as appropriate to provide for the establishment of the essential pediatric oral health benefit, the maintenance of existing patient protections on dental plans, the adequacy of provider networks with robust plan competition and maximizing plan transparency.
Posted: / Last Updated: