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ADA-AAPD comment on Affordable Care Act regulations

January 04, 2013

By Craig Palmer, ADA News staff

Washington—The ADA and American Academy of Pediatric Dentistry urged the U.S. Office of Personnel Management to assure maximum competition among the multi-state plans to be offered through health insurance exchanges.

The OPM requested comments on a proposed rule to implement the Affordable Care Act provision creating the multi-state plan program, which is intended to facilitate establishment of at least two MSPs on each of the exchanges in the 50 states and the District of Columbia. OPM, which will administer the program and certify the plans, called for feedback on the provision of dental services by multi-state plans.

The ADA and AAPD responded Jan. 4 with a joint statement (available on's Advocacy page) signed by the organizations' respective presidents, Dr. Robert A. Faiella and Dr. Joel H. Berg.

“Exchanges must maximize competition among plans to ensure that the exchange marketplace is competitive on January 1, 2014 and beyond,” the professional associations said. “The addition of MSPs could help exchanges meet this goal if those plans offer real value and provide consumers with an adequate network of providers.”

Summary of ADA-AAPD Comments

  • each MSPP issuer should be required to establish an advisory panel of covered patients and participating dentists to provide meaningful input to the issuer on plan policies;
  • to help ensure an adequate network, OPM should make clear that MSP fee schedules will not apply to non-covered services and that plans will be required to make prompt payment of claims, and issuers must be required to offer dentists a separate participating agreement for MSPs offered within the exchange to enable full and fair review by practitioners;
  • individuals who purchase oral health benefits through a multi-state plan deserve equal access to consumer protections irrespective of the plan — medical or dental — used to purchase the dental coverage;
  • patients covered by more than one plan should be guaranteed the full value of their purchased coverage up to 100 percent of the cost of the procedure by requiring a secondary insurer to pay the remainder of the claim up to but not exceeding 100 percent of the amount of the claim;
  • a plan beneficiary should be able to designate payment for covered services to a provider who is not participating in the network so that the patient does not have to pay out-of-pocket and wait for reimbursement by the plan;
  • ADA and AAPD agree with OPM's proposed rule to require that an issuer make its provider directory available to the exchange for online publication and to potential enrollees in hard copy when requested.

The pediatric dental essential health benefit must be a required purchase for all families with children who buy their coverage in the individual or small group market after January 1, 2014 if the children do not already have such coverage,” the statement said. “Stand-alone dental plans and medical plans with an embedded dental benefit must be able to compete on an equal footing inside the exchange to ensure consumers have a robust selection of dental products.”

An ADA-contracted study estimates that some 3 million children will gain dental coverage through the exchanges by 2018, roughly a 5 percent increase over the current number of children with private benefits.

“It is important to note that a significant portion of children will also gain dental benefits outside of health insurance exchanges through, for example, employer-sponsored dental benefits with dependent coverage,” the ADA-AAPD comments said.

“The effects on dentistry could be significant if, for example, the ACA-required essential pediatric oral benefit is inadequate or too expensive or if plans with inadequate dental networks dominate the exchange marketplace”¦The expansion of children's dental coverage in the exchange could be undermined by an interpretation of the ACA that requires the pediatric oral benefit to be offered as one of the essential health benefits but does not necessarily require it to be purchased.”

Pediatric oral health services must be included in the package of essential health benefits offered through the exchanges. The OPM proposes that the benefits for each multi-state plan be uniform within a state but not necessarily among states.

Adequate Provider Networks

“It is important that all dental plans offer an adequate provider network to make the exchange an attractive alternative for consumers,” the dental organizations said. “MSPs should be required to make information about their networks readily available to providers and the viability of the network should be regularly tested.

“Networks should allow all dentists willing to accept the terms of the contract to participate in the network. Also, carriers must be required to offer dentists a separate participating agreement for plans offered within the exchange to enable a full and fair review by the practitioners.

“Individuals who purchase oral health benefits through a MSP deserve equal access to consumer protections irrespective of the plan (medical or dental) used to purchase the dental coverage,” the statement said.

The Office of Personnel Management will administer the multi-state program in a manner similar to its administration of the Federal Employees Health Benefit Program, although the MSPP and FEHPB will remain separate. OPM has the authority to negotiate with each multi-state plan over the medical loss ratio, profit margin, premiums and “such other terms and conditions of coverage as are in the interests of enrollees in such plans.” The proposed rule says that OPM's oversight and contract negotiation experience will “ensure consumers get the greatest value for their premium dollars.”