Understanding embedded pediatric dental plans: What your practice needs to know

September 1, 2015

Unless billing departments understand the new forms of insurance available under the law, dental practices risk losing income due to incorrectly billed claims, delinquent patient accounts and other issues.

Unless billing departments understand the new forms of insurance available under the law, dental practices risk losing income due to incorrectly billed claims, delinquent patient accounts and other issues.

As the two-year anniversary of the healthcare.gov rollout approaches, many dental practices still struggle to adjust to the changes that the Affordable Care Act (ACA) has made to dental insurance in the United States.

Unless billing departments understand the new forms of insurance available under the law, dental practices risk losing income due to incorrectly billed claims, delinquent patient accounts and other issues. Many Americans are embracing embedded dental plans, especially for pediatric dental care. These plans represent a change from more traditional, stand-alone dental insurance plans. Savvy providers must update their billing and insurance practices in order to cope with these new plans.

Related reading: The Ultimate Guide to the Affordable Care Act for Dental Practices

The basics of embedded plans

Before the ACA, most dental customers carried stand-alone dental and vision plans or paid out of pocket. These plans usually offered the same benefits to all members of a family. Under the ACA, plans sold on the exchanges may offer embedded pediatric dental care or the option to purchase a separate, stand-alone dental plan. The new dental plan options can be confusing to both patients and office staff who are used to traditional stand-alone plans. Because ACA-compliant plans may differ from the plans they had in the past, patients depend on office staff to explain their benefits, networks and financial obligations.

In an embedded pediatric dental plan, a medical insurance company includes some dental benefits as part of a health insurance plan. The covered dental benefits are described in the same publication that lists covered pharmaceuticals, orthopedic treatments and other kinds of medical care. The covered dental procedures vary from state exchange to state exchange. On the exchanges run by the federal government, benefits are usually benchmarked to the FEDVIP plans available to government employees.

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Some embedded dental plans are administered directly by the health insurance company. Others are contracted out to companies that also provide stand-alone dental insurance. Embedded plans often view dental procedures through a medical lens. For instance, “medically necessary” orthodontia may be covered, but orthodontic treatments to correct more common issues with bite may not be.

Because insurers on the health care exchanges use narrow networks to control costs, embedded dental insurance plans may have narrower networks than stand-alone plans. Many consumers can’t find reliable information on their dental plan’s network until after they’ve already purchased a plan. Dentists may be unsure whether they’re included in an embedded plan. Some insurers contract with stand-alone plans to manage their networks, so it’s possible for a dentist to be in-network for an unfamiliar embedded plan. Office staff must take extra care when dealing with embedded plans because they’re unfamiliar and the procedures for medical insurance companies frequently differ from the procedures for dental insurers.

Related reading: 5 products making pediatric dentistry easier while delivering better results

Cleanings aren’t always covered

While the ACA mandated first dollar coverage for preventive care, Congress did not include routine dental cleanings and checkups as preventive medical care. This means that if a child has embedded pediatric dental coverage, his or her parents may be responsible for the full cost of cleanings until they have met their medical deductible. They may also have copays for dental visits. These new terms of coverage may come as a shock to parents who are used to stand-alone dental plans that cover two cleanings a year.

Since parents of patients don’t always understand the new billing procedures, office staff will have to verify insurance information and payment terms before the children arrive for their cleanings. Practices that treat children may need to update their pre-appointment procedures to include a phone call discussing expected expenses with parents. By explaining costs and bills before the child enters the office, dental practices can save time and money later on.

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Don’t focus on the family

Family practices can no longer assume that all members of a family have the same dental plan. However, even the family members themselves may not understand the details of their new plans. According to the Health Policy Institute of the American Dental Association, 35.7 percent of insurance plans offered on the health care exchanges now include embedded pediatric dental benefits. Yet parents often buy stand-alone whole family plans to cover the entire family.

This creates a situation where certain family members may have double coverage. However, traditional rules for determining primary and secondary insurance don’t apply to dental insurance obtained through the health care exchanges. The American Dental Association warns members that when a child has double coverage as a result of a plan purchased on the exchanges, costs must be shared equally between the two plans.

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Billing and office staff must evaluate each member of a family group individually to determine whether any of the children carry insurance plans purchased on the health care exchanges, and whether those plans include embedded pediatric dental care. In many cases, billing staff will have to contact health insurance plans directly to determine what coverage members have. Since they’ll also have to contact the stand-alone dental plans that cover these pediatric patients, billing staff may have to adjust their checklists and procedures for dealing with insurance.

Network nuances

It’s not immediately clear if a given dental office is part of the network for an embedded dental plan. Many health insurance companies contract with dental insurance companies to administer embedded plans. This gives the embedded plans access to the dental insurance company’s provider network. However, a patient’s insurance card will often list only the health insurance company, not the dental insurance subcontractor. Office staff cannot determine whether a patient with embedded insurance is in-network based on the insurance card alone.

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Networks can also cause trouble for family dentists. With stand-alone insurance, parents and children share a network. Entire families often visit the same dental practice. With pediatric embedded insurance, parents and children may have two totally different dental networks. Families who have an established relationship with a specific practice may show up for an appointment only to find that they can no longer share a dental care provider. Until patients become used to the changing nature of dental insurance, office staff will have to deal with these issues.

Medicaid headaches

One final pitfall of embedded dental plans concerns Medicaid. The health care exchanges have resulted in a larger number of children being covered under Medicaid. All of these children receive embedded dental care.

Related article: Why insurance coordinators need to be flexible in today's dental world

Congress offset the expansion of Medicaid by increasing payments to physicians. This was done to increase the number of appointments available to Medicaid patients. However, while the law raises payments to medical practices, it does not increase payments to dental offices. Dentists face an economy where more of their patients have transitioned from traditional dental insurance to Medicaid, and where payments do not keep pace with increasing expenses.

Teaching staff to cope with changes

In 2016, the next phase of the ACA goes into effect. Businesses with up to 100 employees will be required to carry ACA-compliant insurance and may purchase plans with embedded pediatric dental care. American dentists can expect to see more pediatric patients with embedded insurance than ever before.

How can practices adjust to the challenge of embedded dental plans purchased on the health care exchanges? A well-trained staff will be able to adjust existing policies to meet new demands and create new routines for dealing with complex situations. Practices should offer their billing staffs opportunities to learn about embedded pediatric dental plans and the options for dealing with new plans. Links2Success can offer training and education on billing issues including embedded pediatric plans. With education, training and experience, dental practices can weather the difficulties posed by embedded pediatric dental plans.

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About the author

Christine Taxin is the founder and president of Links2Success, a practice management consulting company to the dental and medical fields. Prior to starting her own consulting company, Ms. Taxin served as an administrator of a critical care department at Mt. Sinai Hospital in New York City and managed an extensive multi-specialty dental practice in New York. With over 25 years’ experience as a practice management professional, she now provides private practice consulting services, delivers continuing education seminars for dental and medical professionals and serves as an adjunct professor at the New York University Dental School and Resident Programs for Maimonides Hospital in New York.

Ms. Taxin is passionate about helping dental practices reach their highest potential and increase their profitability. In her consulting work she focuses on helping practices strengthen their communication skills, their ability to work as a team and their capacity to set goals. She helps team members develop their latent strengths and improve their effectiveness and job performance. Ms. Taxin’s specialties are creating highly efficient administrative systems, consulting on valuable internal and external marketing efforts, providing strategies for successful financial planning and educating practices on advanced dental and medical billing techniques.

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