KDA Today

KDA Today

For Immediate Release

Date: Apr 15th, 2013
Contact: Dr. John Thompson
Phone: 800-292-1855
Email: info@kyda.org

Exchange What?

Regardless of your politics, the Affordable Care Act (ACA) is the law and the changes that will occur in 2014 will affect the practice of dentistry in Kentucky. At the urging of the KDA, I was appointed to the Kentucky Health Benefit Exchange Advisory Board. I am one of nineteen members, and I was appointed to represent the interests of non-facility-based providers. I have been a wet-finger dentist for forty-two years and I am the only dentist on this board. I have provided advice and sought to bring others who would provide specific expertise to the table as members of our board and subcommittees. We have worked under very tight schedules to address issues involving pediatric oral and vision care, which is one of the ten categories of Essential Health Benefits (EHB). A health benefit plan must cover the EHB package before it can be sold through an exchange or on the commercial market beginning January 1, 2014. Yes, there is a dental component to the ACA. The tenth EHB category includes a Pediatric Dental Benefit (PDB) that will apply to dependent children up to 21 years of age in Kentucky.

In order to understand this commentary, you now have been exposed to a series of acronyms. You will need to become familiar with this alphabet soup as you read this or discuss issues involving the new laws of health care. Again, those acronyms are:

ACA- Affordable Care Act
EHB- Essential Health Benefit
QHP-Qualified Health Plan
PDB-Pediatric Dental Benefit
KHBE-Kentucky Health Benefit Exchange

There is a myriad of other acronyms we can introduce, but I am too confused as I read the Health and Human Services bulletins, regulations and Federal Register to even consider sharing my condition of confusion with you.

The state of Kentucky, under the executive order of Governor Steve Beshear, elected to form a state-based Exchange that is managed by Kentuckians. This does give our state a modicum of control under the directives of the Federal Department of Health and Human Services (HHS). There has been much said in the press with regard to the many states having elected to have the federal government run their state exchanges. The jury may be out as to whether this is a good thing, but I have personally found it hard to believe that many conservative Republican governors have chosen to let the federal government operate their health benefit exchanges. I do now believe that some control is much better than no control and the citizens of Kentucky will be better served by local, rather than national interests.

In October of this year, individuals and small businesses in Kentucky will be able (under the ACA) to apply for health insurance coverage and, if eligible, purchase a QHP through the KHBE. Why would someone choose a plan through a state managed Exchange? The first answer is very simple. Any low income individual or family above 100% and up to 400% of the federal poverty level may request premium assistance if they purchase their QHP through the KHBE. The second answer is that premium assistance is only available for QHPs purchased through the Exchange and not available if purchased outside the Exchange. The third answer is that except for certain individuals identified in the ACA, a tax penalty may be imposed on any taxpayer who fails to maintain minimum essential coverage beginning in 2014.

Beginning in 2014, every QHP on the Exchange must offer individuals the opportunity to purchase a Pediatric Dental Benefit (PDB) for their dependent children under the age of 21 years. In Kentucky, that dental benefit will reflect the KCHIP menu of benefits, not the fee schedule. If you are familiar with the KCHIP benefit (or go online at http://cciio.cms.gov/resources/data/ehb.html, if you are not) you will see that this is a fairly well defined and inclusive list of services that can insure the oral health of young Kentuckians. There is a provision limiting orthodontics to medically-necessary provisions. There will be no annual or lifetime maximums and, at present, there is in discussion, a $1,000 out-of-pocket limitation. The KCHIP menu provides the limit of provisions within a plan that may be considered for premium assistance as this is the EHB of any QHP. This does not mean that additional benefits cannot be purchased for children, including orthodontics. It does not mean that a complete family plan cannot be purchased. It simply means that benefits beyond the EHB will not be considered for premium assistance on the Exchange. These plans have been available in the past and will continue to be offered in the future; however, only the pediatric dental essential health benefit will be clearly defined to constitute a required EHB of a QHP.

What will these plans look like? Although no QHP forms have been filed by insurers at this time, it appears that most QHPs may not have an embedded dental benefit due to the unique nature of what has been called dental insurance. Inside or outside the exchange, an insurer may offer a QHP with the nine EHB’s and a stand-alone PDB could be purchased as the tenth EHB that will make the purchased plan a QHP. That combination of the health benefit plan with coverage of nine EHBs and the stand-alone PDB plan will constitute a health insurance plan that meets QHP requirement of the ACA.

What will a PDB plan cost the consumer? We can only estimate at this time what those costs will be because the regulations and actuarial details are only now in process. Additionally, the insurers have not filed rates for QHPs which include the PDB.

I have not even attempted to discuss how a dental practice, as a small business, will be impacted by the changes that will occur in October 2013, when plans will be available for purchase through the state-run Small Employer Health Options Program (SHOP). I will not bring into the equation the impact that may occur if Medicaid eligibility is expanded. These are entirely different messages that will be addressed later this year. I want you to know how the ACA will impact this Commonwealth as it brings dental benefits to an unknown but significant number of children whose access to dental care will be substantially enhanced by having pediatric dental benefits as an EHB for these next two years.

For the calendar year 2016, the State EHB package will be reevaluated and changes may occur. The dental profession lobbied long and hard to have the PDB included as one of the ten EHB categories. It is my personal opinion that the people of this Commonwealth and the dental profession will be served well by making this a very successful partnership. To say that there will not be flaws in the system when it rolls out is absurd. Change often presents a threat, in itself. These changes have the potential to improve a dismal record of oral health in Kentucky. We, as a profession, have the opportunity to demonstrate that improved oral health access is essential to a total health package and that we have the ability to meet the demand and solve the administrative challenges that will occur.

These comments do not necessarily reflect the position of the KHBE or its Advisory Board. They do reflect my personal opinions and observations as editor of KDA TODAY.

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