The Trouble with Dental Reimbursement in America

Patients struggle to afford quality dental care due to rising costs, inadequate insurance, and low reimbursement rates. Poor insurance rates also affect dentists. States and the federal government are stepping up to improve accessibility and affordability.

By Theresa Ahearn

Dental care is essential for overall health, but the high cost of treatment is a significant concern for many Americans. Even those who have dental insurance often face high out-of-pocket expenses due to reimbursement issues. The American Dental Association (ADA) reports that the average cost of a comprehensive oral evaluation in 2020 can range from $87 to $126 and beyond. More complex procedures can cost up to $1,000 for a root canal and over $3,000 for dental implants. Unfortunately, insurance companies often reimburse dental providers at lower rates than other medical providers, reducing dental practices' revenue.

The Flawed Dental Insurance System

Dental insurance can be an overwhelming and complicated topic for numerous patients. Due to the dental insurance industry's profit-driven approach, insurance companies establish fee schedules that may not accurately reflect the actual costs of dental services, resulting in a flawed system. Even for those with dental insurance through their employer, the maximum benefits available are typically limited to $1,500, often insufficient to cover modern dental treatment costs and advanced dental technology.

Dentists should provide patients with a thorough explanation of the two primary types of dental insurance policies, namely Dental Maintenance Organizations (DMO) and Preferred Provider Organizations (PPO), and assist them in navigating the differences between in-network and out-of-network providers. In addition, understanding dental insurance's essential terms and concepts, including Annual Maximum Benefit, Copayment, Coinsurance, Covered Services, Deductible, and Explanation of Benefits (EOB), is critical for patients to make informed decisions about their oral health care while operating within the limits of their insurance coverage.

For elderly Americans, Medicare, which covers healthcare for seniors and those with disabilities, does not typically provide coverage for most dental services, including routine check-ups, cleanings, fillings, extractions, and dentures. Private insurance providers also do not typically offer comprehensive dental coverage, with many policies only covering a percentage of treatment costs and having strict limits on the types of procedures covered. This results in significant out-of-pocket expenses, leading many individuals to forego necessary dental care.

Unfortunately, despite insurance options, many Americans remain uninsured or underinsured. In 2019, nearly 25% of the U.S. population, or 74 million Americans, had no dental insurance and could not afford to pay for expensive dental care out of pocket. The COVID-19 pandemic has exacerbated this problem by causing inflation and leaving millions without jobs. As a dentist, it is critical to educate patients about their insurance alternatives and collaborate with them to establish a treatment plan that suits their budget and requirements. Furthermore, as members of the dental profession, it is essential to advocate for expanded dental benefits and comprehensive coverage for all Americans.

How State and Federal Initiatives Are Addressing Dental Care Insurance Issues

States and regulatory bodies are trying to address ongoing insurance reimbursement issues in dental care. One possible solution is the implementation of alternative payment models, such as Dental Service Organizations (DSOs), which aim to increase care delivery efficiency while reducing costs for patients and providers. The White House has proposed adding a dental benefit to Medicare as part of a $3.5 trillion human infrastructure plan. President Biden wants to strengthen the program and expand healthcare access for older Americans. Federal agencies are exploring ways to improve Medicare and Medicaid by broadening coverage for specific services and lowering beneficiary costs. President Biden has also introduced legislation to expand Medicare to cover dental, vision, and hearing services, which are currently not included.

In addition, the proposed American Families Plan includes funding for dental care to enhance healthcare access, especially for low-income and underserved communities. The administration has also suggested increasing funding for community health centers, which frequently provide dental care services to uninsured or low-income individuals. Congressional approval is needed to implement changes to Medicare and dental care, so the specific actions to improve these areas of healthcare are currently unknown.

Several states are taking individual initiatives to help dentists and patients address insurance and reimbursement concerns. For example, Minnesota is reviewing a bill that proposes redefining "covered services" under dental insurance policies to increase dental providers' reimbursement rates, making dental care more accessible for patients. California has launched multiple programs to improve access to dental care, including the Dental Transformation Initiative, which provides funding for community clinics and other providers to increase access for low-income patients. The state has also launched the Virtual Dental Home program, which uses telehealth technology to provide preventive and restorative dental services to underserved populations.

Oregon has implemented several innovative programs to improve access to dental care, including the Dental Health Aide Therapist program, which trains mid-level dental providers to deliver preventive and basic restorative services in underserved areas. The state also provides grants to dental practices that serve low-income patients and has expanded the availability of dental benefits under Medicaid.

In Conclusion

Dental insurance and reimbursement issues continue to be a significant concern for many Americans, making it difficult to afford quality dental care and run a profitable business. While states and the federal government are making efforts to improve accessibility and affordability, there is still much work to be done.

Dental professionals must educate patients about their insurance options and advocate for expanded dental benefits and comprehensive coverage for all Americans. With the implementation of alternative payment models and the proposed addition of dental benefits to Medicare, there is hope for improving access to dental care for low-income and underserved communities. Collaboration between dental professionals, states, and governments can help ensure that every individual has access to the dental care they require for optimal oral and overall health.


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Author: Theresa Ahearn is a freelance writer currently residing in Oak Ridge, Tennessee. She received her Bachelor of Arts from the New York Institute of Technology and her Master of Science from Central Connecticut State University. When not writing, she can be found fishing or traveling someplace new.

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