Proposed National Oral Health Insurance changes could impact NC benefits

Written by Anne Bryce

This may not be mentioned often in everyday conversation, but it's important, especially when thinking about your overall health.

The mouth is where the digestive process begins. It is also an important part of the respiratory system.

These things may be obvious to many people. Oral healthcare professionals may wonder, then, why what's inside the mouth — teeth and gums — is given less importance when it comes to insurance and other medical benefits.

In a letter from its leaders to Chiquita Brooks-LaSure, administrator of the federal Centers for Medicare and Medicaid Services (CMS), earlier this month, the American Dental Association explained why it should not do so. explained.

The Jan. 4 action was prompted by the announcement late last year that more adults would be able to obtain dental insurance in the Affordable Care Act (ACA) marketplaces if proposed rule changes go into effect.

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

The changes are expected to take effect in 2025, but states will have the final say. States would not be required to include dental services, as proposed, but would no longer be prohibited from including such medical services as essential for adults.

Pediatric dental services are considered an essential benefit. as well as primary care, substance abuse, and outpatient services.

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

According to the proposed rule change, by adding such services as mandatory benefits, states would be able to “improve adult oral health and overall “It gives you the ability to work towards improving health outcomes.” .

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

mouth and body

Oral surgeons, dentists and hygienists have struggled in recent years to dispel the notion that oral health is not closely related to overall health.

“Untreated oral health conditions can increase the risk of, and complicate the management of, other chronic diseases,” the proposed rule change states. “For example, research shows that periodontal disease and tooth loss are strongly associated with heart health, and that taking good care of your oral health can reduce your risk of cardiovascular disease, atrial fibrillation, and heart failure.”

According to the federal government, further research shows that people receiving treatment for substance use disorders are more consistent with their treatment plans, both in the facility and after discharge, if they receive comprehensive oral health care. has been done.

Having a healthy smile can also contribute to your employability, federal officials added.

“About 30 percent of low-income adults in the U.S. and 60 percent of Medicaid recipients without access to dental insurance report that job interviews are limited because of the appearance of their mouth and teeth.” Regulations The changes are listed in the documentation.

Medicaid dental benefits

Similar points have been made in North Carolina.

In December, as many as 600,000 people gained access to expanded Medicaid health insurance and became eligible for oral health benefits.

State Medicaid programs provide regular cleanings, oral health exams, and other preventive services through comprehensive oral health benefits packages.

The problem is that only about 45 percent of dentists in North Carolina accept Medicaid patients. And many of these dentists are not accepting new Medicaid recipients, leaving gaps in coverage across the state.

Oral health advocates who are lobbying for more dentists to consider treating more Medicaid recipients say providing preventive care can help reduce the extreme pain caused by infected gums and crumbling teeth. He said it could keep people with medical conditions out of the emergency room. Such care may also be beneficial in improving the mental well-being and economic viability of people with healthy gums and teeth.

“North Carolinians deserve an oral health care system that contributes to their overall health,” said Frank Coates, president of the North Carolina Dental Association Oral Health and Prevention Council, in a letter published in Noise News. I mentioned it inside. “It is incumbent upon state leaders to find ways to adequately fund dental care for Medicaid recipients. Achieving this will save the state money in the long run and improve the health and productivity of our population.” To do.”

gradual progress

It is unclear whether there would be a broader impact on North Carolina if adult dental services became an essential health benefit in Affordable Care Act marketplace insurance plans.

This year, nearly 1 million North Carolinians will have health insurance coverage under individual insurance plans in the Affordable Care Act Marketplace. Others receive insurance through work or state and federal programs such as Medicaid and Medicare.

About 110 million Americans had private dental insurance in 2020, according to the Centers for Medicare and Medicaid Services. Nearly 91 percent of them received dental benefits through their employers or organizations such as AARP, the federal agency added.

When developing essential health benefits in the early days of the Affordable Care Act, federal officials focused on what employers provided. Dental insurance plans are often offered as an additional charge by employers, so oral health care has generally been excluded as a requirement in federal marketplace plans.

In a letter to the federal government supporting changes to essential medical benefits, American Dental Association leaders emphasized the importance of specifying required oral care services.

They proposed including diagnostic, preventive, emergency and restorative care. Additionally, the ADA proposed to include oral and maxillofacial surgery, pulp and root canal therapy, treatment of gingival and oral tissues, dentures and other prosthetics, and orthodontics.

Such marketplace plans must allow dependent children to remain on their parents' plans until they reach age 26.

The National Dental Association also called for consumer protections covering plans sold in federal and state marketplace plans.

“The ADA supports stronger policies regarding reasonable warranties to enable individuals and small groups, both in and out of the marketplace, to provide adult dental benefits to consumers,” the letter states.

Medicare has already shifted to “needs”

North Carolinians who receive Medicare, a program that covers seniors and many people with disabilities, won't have to wait long for dental insurance coverage.

Late last year, the Biden administration announced changes to Medicare payment policies to clarify the interpretation of “medically necessary dental services.”

According to KFF, an organization that tracks health policy research, eligibility has been expanded to include any dental or oral exam before organ transplant surgery or heart valve replacement surgery.

This year, Medicare will cover dental treatment needed after radiation therapy, chemotherapy, and head and neck cancer-related treatments.

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

“Although these rules slightly expand the types of dental services covered by Medicare, they do not include coverage of routine preventive services such as exams and X-rays, as well as broader coverage of dental services. “It does not significantly expand the scope of services; it provides services, including root canals and dentures, to all Medicare enrollees,” KFF analysts wrote in their discussion.

“Unless dental insurance coverage under Medicare is broadly expanded, Medicare enrollees without other comprehensive dental insurance will find it relatively expensive, especially if they need extensive dental care not related to other insurance.” “Health care services will continue to face significant out-of-pocket costs,” KFF concluded.