How do you manage the new ACA out of pocket amounts?

Dental insurance in the ACA

ACA Dental Insurance Effects

Do you have any families in your practice that have purchased dental insurance through your state’s health insurance Marketplace?

I just read a parents guide for “Buying Children’s Dental Coverage through the MarketPlace” and was interested in how this affects dental practices on the management side. Here’s a graphic taken from this guide (Click to read the entire guide):

Dental insurance in the ACA











So, as I understand this infographic, there are two ways a family can get dental insurance. Let’s start by looking at the right side of this graphic. The right side shows separate medical and dental – most offices are used to this.  However, it shows that their dental plan has a $700 limit on what the patient spends. This is completely opposite from how our dental insurance modules in our software work! Now, we’re used to the patient paying their deductible, then their insurance will kick in usually up to $1000 and the patient is responsible for his co-pays and anything beyond the insurance maximum.

Separate Medical and Dental Insurance

This graphic is showing completely the opposite from what we’re used to seeing for managing dental benefits. This has  no mention of deductible and no maximum for the insurance company! Instead, the most the patient has to pay is $700?!   At first blush, this sounds great! But there are a couple big “BUTS” here – first of all, this is a Childrens Dental Coverage guide, so you can’t start daydreaming about treatment planning implant cases and having the patient responsibility only at $700 with the insurance covering the rest. Next, these plans are covering preventive care, xrays and exams, and fillings only. I’m left to wonder how these handle a stainless steel crown or an extraction. In dentistry, we know how many kids with decay are having teeth extracted – does this mean that Mom and Dad pay out of pocket for this specific treatment?

This just went from sounding great to sounding like a nightmare when a dental office manager tries to explain to the Mom that some of her 9 year old’s treatment is covered by insurance but other is not – and its based on the individual code. And, we will somehow have to explain that even though your plan says your maximum out of pocket is $700, you could easily pay far more than that because that doesn’t include certain procedures. I imagine this conversation going something like this:

Dental Office Manager: “Yes, Mrs. Jones, I understand that your ACA dental insurance plan says your maximum out of pocket expense is $700. However because Johnnie needs 3 extractions and 2 stainless steel crowns, these will not be covered and that brings your total up to $1000 plus the $700 co-pay for the exam, cleaning, xrays and fillings.”

Mrs. Jones: “What?!?! But I bought this dental insurance plan because it says it will pay everything and all I have to pay for is $700! This is a rip off! You people must be figuring this wrong.”

Now, lets imagine preparing these treatment plans. Our dental software will default to the traditional insurance rules it knows – it has no field to plug in the $700 out of pocket maximum. However, since that maximum only applies to the diagnostic, preventive and only certain restorative codes, how would that be entered in the first place? The craziest part of this is the D2000 codes – the $700 max will count on the fillings but not on the crowns. When I want to set my Dentrix insurance coverage for a specific code (let’s say the plan covers 80% on the D4910 perio maintenance procedure but 50% on all the rest of the perio codes) then I can separate the D4000 codes to before and after the perio maintenance code and enter the proper percentages. However, that takes several minutes and you have to really know what you’re doing. I wonder how this would be set up for one of these new ACA plans?

Combined Medical & Dental Insurance

Go back up and look at the left side of the infographic. This shows a combined out of pocket expense for the family of $6350/year. As I think of my fellow dental office managers, I groan to imagine that we are somehow going to have to find out how much the family standing in front of us has already spent on their health insurance this year, just so I can tell them how much of their dental visit they will have to pay for! Anyone who has ever called a health insurance plan can tell you what a giant waste of time that is. I have called health insurance plans to find out about sedation coverage for children undergoing significant dentistry and have been transferred to the dental side of the house (if one exists) as soon as I say the word “teeth” – I can only imagine how confused the representative on the other end of the line will be when I explain that I need to know how much the family spent out of pocket?! In fact, I’ll guess that the representative will quote their HIPAA Privacy Policy as the reason they refuse to provide that information.

Just from an overhead standpoint, I can’t imagine that dental offices can invest the administrative time to contact the health insurance plan on behalf of the patient. And, just like I’ve seen with sleep apnea appliances – this coverage won’t end up benefiting our patients anyway. If the family with this plan doesn’t meet their out of pocket of $6,350 then they’re not going to receive any insurance benefits whatsoever. Just like sleep apnea patients who cannot wear a CPAP and have a sleep physician’s prescription for a dental device – unless the patient has already met his/her medical insurance deductible (usually $1500 or more in today’s world of high deductible health insurance plans) they’re going to pay out of pocket for this appliance.

What is your experience?

These are just thoughts I’m having as I read through this buyers guide because so far the different offices I’m working in are not running into families with these type of dental plans. Frankly, I’m happy that we haven’t had to figure out how to tackle these insurance estimates yet, but as time goes by, I’m sure that will change. If anyone reading this article has run into these type of plans, would you please comment about how you are handling these families? Have you come up with an approach that seems to work? How do you handle the treatment plan estimates?

Thanks for sharing.

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AUTHOR: Jill Nesbitt
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