Among the many unknowns that come with the implementation of the Patient Protection and Affordable Care Act is one that could hit consumers right in the teeth: orthodontic reimbursement. Pediatric dental, says Evelyn Ireland, executive director at the National Association of Dental Plans, isn’t going anywhere, but parents and others planning on braces should also brace for some cost-shifting.

“Orthodontia is one of the big coverage differences that [may] occur for pediatric dental,” Ireland says. “Pediatric dental in the proposed rules is defined as any enrollee up to [age] 19. So, the way [PPACA] is structured, pediatric dental is a benefit that is described as part of the essential health benefits that will be offered in the small group and individual market. Of course, the small group market includes exchanges.”

Ireland says one of “the biggest changes” to dental coverage may come from establishing categories of orthodontic needs.

“Pediatric dental … does not include cosmetic ortho, which is kind of problematic because there’s not a definition of cosmetic ortho,” she says. “The original definition said it would include medically necessary ortho; we’ve asked them to clarify.”

Orthodontia, as Ireland points out, “is not preventive care,” and thus does not get much largesse from PPACA. So, how many braces, head gear and mouth guards would qualify for financial assistance? Only about 30% of them, Ireland says.

“If 70% of the people who currently could get reimbursement for orthodontia don’t get it — that’d be a big shift in coverage,” Ireland says. “[Between birth and age 20], 18%-19% of all children have an orthodontic procedure, so roughly one-third of those would continue to be covered. All the rest of them would not have any coverage under the essential health benefits package.

“Now it’s anticipated that on exchanges and in the private market, too, there will be various wrap options where you can add on coverage for the family, for adults, for older children — there might be some orthodontic coverage in that. The other big change in the way ACA is structured is there’s no annual or lifetime maximum … and that also applies to pediatric dental.”

Ireland says “the way the coverage works in terms of reimbursement remains to be seen,” but, “if it’s similar to a policy today, ortho is around 50% covered.” With the national average cost of an orthodontic claim at around $6,250, there’s a big range of how that bill could get diced up.

“They could end up paying anywhere from $4,000 or $5,000 to only paying $1,000,” she says. “That’s a huge difference.”

Any cost-shifting, Ireland says, messes with a fragile system. Dental coverage in general could suffer, and “the deterioration of oral care” would follow as those with dental insurance go to the dentist 2.5 times as much as those without.

“Most employers are going to continue to offer dental as a supplemental policy, something the consumers can add on, but they might reduce their contribution towards it or make it a totally voluntary program,” Ireland says. “I don’t think the vast majority of employers would just drop the coverage, but they could do enough cost shifting to the consumer that it could significantly impact the enrollment rates. Right now, we’ve stayed at 57% of the population coverage, except for a dip in 2010, but that dip, because of the economy, was pretty significant. It was about a 10-million person dip, and we could see that kind of dip again.”

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