But will a question about dental insurance on the November ballot improve coverage? Or, as opponents claim, will it mainly increase costs? This is the confusing part. Here are some answers.
How we got here
The Affordable Care Act created benefit requirements for health plans and established a framework to hold insurers accountable for quality and spending. Pediatric dentistry was included as an “essential health benefit,” and insurers were required to set annual caps on the percentage patients could be asked to pay out of pocket for certain procedures for pediatric dental benefits.
But unlike medical benefits, which under the ACA must include free annual medical exams and other preventative care, adult dental insurance has no such requirement.
Under state law, Massachusetts medical insurers must also spend 88% of the premiums they collect on patient care, also known as the medical loss rate. Such conditions do not exist for dental insurers.
As a result, most agree that dental insurance comes with more limited benefits.
Dr. Andrew Tonelli, a dentist practicing in North Reading and co-chair of the Massachusetts Dental Society’s government affairs committee, said that when it works well, especially when subsidized by an employer, dental insurance can help patients. access care. But some insurers, he says, impose annual maximums on how much dental insurance will pay for care, and caps have remained relatively unchanged for decades, despite inflation. Many plans also come with high cost sharing — the percentage of a procedure’s price that patients have to pay out of pocket, Tonelli said.
The dentist then needs to figure out what the insurance will actually pay and communicate that to the patient, said Tonelli, who is also a spokesperson for Massachusetts Dental Providers for Better Dental Benefits, a group that originated the question. of the ballot.
“We have a lot more people thinking about dental insurance than we have doing dentistry,” he said.
How could the ballot measure help?
The ballot question would establish what Tonelli said is consumer protection around dental insurance. Similar to medical loss ratio laws for medical insurance, the ballot would require dental insurers to spend 83% of the premium they collect on claims. Based on 2019 and 2021 data of a study commissioned by According to the National Association of Dental Plans, the three largest insurers in Massachusetts spend about 76% of their premiums on dental claims. (Data from 2020 was not included in the study.)
The ballot question dictates that if insurers didn’t spend enough to meet the threshold, they would have to return the money to Massachusetts consumers in the form of rebates.
Tonelli pointed to 2020, when most dentists closed their practices for three months for all but emergency procedures due to COVID. Yet people continued to pay their premiums. Unlike medical insurers, who were required to return most unused money to consumers, dental insurers had no such obligation.
Massachusetts’ Delta Dental, the state’s largest dental operator by membership, said it voluntarily refunded $24 million to customers in rebates in 2020. It was unclear what percentage of premiums it had perceived this represented.
According to Tonelli, the obligation to respect certain payments would encourage insurers to enrich their social benefits.
The ballot measure would also broaden the Insurance Division’s review of the premiums charged by dental insurers, to help prevent insurers from blatantly raising premiums to offset new spending requirements.
“People have an underlying feeling that things aren’t getting better,” Tonelli said. “But here is a tool. If patients and voters vote yes, maybe we can improve the system.
What are the opponents saying?
David Shore, board member of the Massachusetts Association of Health Underwriters, said if the ballot measure passes, insurers would still have much of the same administrative costs as before, but would now only be allowed to use only 17% of the premium they collect. to pay it. As a result, insurers would likely increase their premiums, covering their costs by collecting a smaller percentage of a larger amount.
While medical insurers are held to the kind of thresholds included in the ballot question, their premiums are approximately 19 times higher than average dental premiums, according to Shore.
Shore said insurers could do other things to meet the new requirements, such as reducing administrative costs, paying dentists more per service or reducing out-of-pocket payments to patients by enriching their coverage. But regardless, “premiums will have to go up,” Shore said, since the insurer’s budget is a percentage of the premium, he said.
Tufts University’s Center for State Policy Analysis, which released a report on the ballot issue, did not suggest premiums would rise, but said the amounts insurers pay dentists could rise, although “the magnitude of these increases should be limited”. says the report.
Proponents of the ballot measure point out that insurers would have to seek approval for premium increases from the Division of Insurance, which could prevent them from raising excessively. In the study commissioned by the National Association of Dental Plans, researchers admit that increasing premiums to comply could be particularly difficult, given the DOI’s ability to reject increases.
In a market where premium increases are necessary but hard to get approved, the Committee to Protect Access to Quality Dental Care, a group opposed to the ballot, said the market is likely to consolidate. or that certain carriers leave Massachusetts.
“Remaining carriers will likely reassess their ability to maintain lower-cost plans that serve more vulnerable populations, which will reduce consumer choice,” the committee said in a statement.
How far premiums might increase even with state oversight is unclear. The division said it works behind the scenes to negotiate medical insurance rates, often landing on increases lower than what companies submit. Public rejection of rates is rare.
Only a subset of the state insurance market is expected to buy into the new measure if passed. Indeed, a significant portion of the market is made up of large employers who pay their employees’ healthcare costs directly. These “self-insured” employers are not bound by state insurance laws. However, Shore said the ballot issue could inflate the cost of dental care for everyone. If insurers pay dentists more per service to meet the requirements of a new law, that could mean higher premiums for the overall market.
Consumer advocacy group Health Care For All took no position on the ballot issue, but was also skeptical of some of its benefits.
“Dental insurance plans should have more financial transparency and accountability, however, the ballot initiative is not likely to improve consumer access to oral health care,” said the organization in a press release.
What else can be done to improve dental coverage?
Shore said creating quality metrics and incentivizing care that measurably improves people’s oral health would help improve dental coverage. For example, insurers could rethink how dentists are paid to reward them for spending money on things like preventative care or more personalized care.
Chad Olson, director of state government affairs at the American Dental Association, said the national organization is working on a number of dental insurance reforms beyond medical loss ratios, including instituting minimum coverage requirements for insurance. But the Massachusetts ballot question highlights an area that, if successful, would become a national model.
“A lot of eyes are on Massachusetts,” he said.
Jessica Bartlett can be contacted at jessica.bartlett@globe.com. Follow her on Twitter @ByJessBartlett.
