For some, the premiums may not make the coverage worth it. Low payment rates often limit access to those with dental coverage through Medicaid
An oral health problem is often the body’s canary in the coal mine. According to the Academy of General Dentistry, more than 90% of human diseases — everything from cancer to heart disease to infectious diseases — first present as symptoms that affect the mouth.
But in the United States when it comes to insurance coverage, oral health and dental care have been severed from other healthcare coverage. According to the American Dental Association (ADA) Health Policy Institute, one-third of adults and about 1 in 10 children don’t have dental coverage. In some cases, people elect not to have coverage, calculating that their out-of-pocket costs for the routine services covered by a dental insurer will be less than the cost of a year’s worth of monthly premiums. “The benefit is typically sold separately, and not everyone purchases it,” notes Adam C. Powell, Ph.D., president of Payer+Provider Syndicate, a healthcare consulting company in Boston. “As the costs of dental care are typically much lower than the costs of medical care, many people cover the costs of dental care out of pocket instead of buying dental insurance.”
Dental care is another fissure in American healthcare that both causes and reflects deeply rooted inequities. Black and Latino children and adults and people who live in historically underserved urban and rural communities report lower rates of dental care than the general population. Among adults aged 20 to 64 years, nearly twice as many Black and Mexican American adults have untreated cavities as White adults. A shortage of dentists in low-income neighborhoods and family financial constraints are among the chief obstacles preventing children in lower-income families from receiving dental care, says Fred DiOrio, D.M.D., dental director of government programs at Horizon Blue Cross Blue Shield of New Jersey.
More than 200 million Americans have some kind of dental care coverage, and about half of employers offer their employees a dental plan. Dental insurance coverage offered by employers is traditional noncatastrophic coverage that provides discounts and full coverage for preventive services such as cleanings, but limited coverage for acute services, Powell says. Most plans offer comprehensive coverage for diagnostic and preventive care and varying levels of coverage for restorative care such as fillings, crowns, dentures and oral surgical procedures. Orthodontia and cosmetic dentistry are covered less frequently.
While many plans have an annual maximum benefit of up to $1,000 or $1,500, most consumers rarely exceed their annual maximum benefit from year to year, according to Scott Towers, president of the dental division of Anthem. Edward A. Murphy, MBA, executive vice president, dental, Life and Specialty Ventures in Little Rock, Arkansas, a subsidiary of Florida Blue, says most employer-based dental coverage is adequate for most employees. However, deductibles and annual coverage maximums limit the extent of overall coverage.
The public payers in the United States — Medicare, Medicaid, the Federal Employees Health Benefits Program, Tricare — also play a large role in dental coverage and therefore access to dental services.
Dental services are a required service for most Medicaid-eligible people under age 21 years. Most states provide at least emergency dental services for adult. About 30 cover preventive and restorative services like fillings. Medicaid payment for dental care is often far less than what employer-based dental plans pay, so many dentists turn away patients whose care would be paid at Medicaid rates, or they restrict the number of Medicaid patients they see, Towers says. As of 2019, less than half (43%) of dentists in the United States accepted Medicaid or the Children’s Health Insurance Program (CHIP), according to the ADA Health Policy Institute.
Traditional Medicare doesn’t cover dental care. One version of Democrats’ Build Back Better legislation would have expanded Medicare to cover dental services as well as vision and hearing services. A later version limited the expansion to just hearing services. However, most of the increasingly popular Medicare Advantage plans include some dental care coverage. The benefits can include preventive services, such as cleanings, as well as more comprehensive benefits including restorations and crowns, says Quinn Dufurrena, D.D.S., J.D., chief dental officer at United Concordia Dental, a dental insurer headquartered in Camp Hill, Pennsylvania.
Some trends are pointing toward more Americans gaining dental coverage. “Within the private sector, cost tends to be the biggest obstacle to coverage and payers continue to innovate and expand cost-effective benefit plans tailored to a wide audience, including underserved communities,” Towers says. Some health plans are embedding benefits in select plans to encourage whole-person health.
In addition, some plans are increasing annual maximums to provide broader benefits. DiOrio says dental practices are increasingly willing to enter into value-based arrangements with insurers. Similar to value-based arrangements in other areas of American healthcare, these dental value-based arrangements tie payment to quality-of-care measures and other factors.
The ACA has extended dental insurance coverage to more Americans by virtue of Medicaid expansion, although the low payment rates often create an insurmountable barrier to actually getting care. Thirty-eight states and the Washington, D.C., have expanded Medicaid under the ACA. Moreover, in many states, the number of people covered by Medicaid has increased since the beginning of the COVID-19 pandemic last year because people lost jobs that provided employer-based health and dental insurance.
But for adults, dental coverage isn’t one of the ACA essential health benefits, so it doesn’t need to be included in the coverage provided by the health plans sold on the ACA exchanges. Dental coverage is an ACA essential health benefit for children so dental coverage for people aged 18 years or younger must be available, either as part of the health plan or as a stand-alone plan.
The integration of medical and dental benefits results in better health outcomes, says Susan Fleischman, M.D., chief medical officer at Blue Shield of California. Based on the insurer’s review of groups with both medical and dental coverage, the per-member, per-month cost of healthcare has been consistently 3% to 6% lower in plans that offer medical and dental coverage together than in those that cover only medical services.
But adding benefits to health plans increases premiums. “Given the relatively modest cost of most dental care relative to medical care, many people can forgo dental insurance without experiencing substantial additional financial risk,” Powell says.
Karen Appold is a medical writer who lives in the Lehigh Valley region of Pennsylvania.