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ADA, AAPD file joint comments with CMS

Organizations ask agency to expand procedures included in value-based insurance, continue automatic reenrollment

March 03, 2020

By Jennifer Garvin

Baltimore — The American Dental Association and American Academy of Pediatric Dentistry filed comments Feb. 28 on the Centers for Medicare and Medicaid Services’ proposed 2021 notice of benefit and payment parameters for the Affordable Care Act.

In a joint letter to CMS, ADA President Chad P. Gehani and AAPD President Kevin J. Donly stressed the need for “adequate and appropriate preventive care coverage as the basis to assure value in a dental plan.”

The two organizations said they appreciated CMS’ soliciting feedback on stand-alone dental plans in value-based insurance designs but urged the agency to consider comprehensive preventive oral health practices in the future as an effective means of promoting optimal oral health.

To do that, they recommended CMS to include the following procedures as covered services in all dental benefit plans:

• Prophylaxis and periodontal maintenance services.
• Topical fluoride applications.
• Application of pit and fissure sealants and reapplication as necessary.
• Interim caries arresting medicament application (e.g., silver diamine fluoride).
• Space maintainers at appropriate developmental stages.
• Oral health risk assessments.
• Screening and education for oral cancer and other dental/medical related conditions.
• Preventive resin restorations.
• Resin infiltrations.
• Fixed and removable appliances to prevent malocclusion.
• Athletic mouth guards.
• Prescription or use of supplemental dietary or topical fluoride for home use.
• In-office patient education, (i.e. oral hygiene instruction, dietary counseling and tobacco cessation counseling with regard to the promotion of good oral and overall health).

The ADA and AAPD also noted that in order for plans to be identified as “high-value,” all stand-alone dental plans must provide 100% coverage for these preventive services without additional co-insurance for beneficiaries.

“Further, arbitrary annual frequency limits or age limits without consideration for the patient’s needs does not support the notion of ‘value’ in a dental plan,” wrote Drs. Gehani and Donly. “Plan design should also consider incentives to promote positive patient home care behaviors as well as incentives to support continuity of care.”

Automatic reenrollment is ‘critical’
On CMS’ proposal to reduce the Advance Premium Tax Credit for those enrolled in a plan with zero premium, the ADA and AAPD told the agency that it should continue automatic reenrollment for this population.

“Automatic reenrollment is critical for ensuring that beneficiaries continue to be enrolled and do not lose coverage due to forgetfulness, lack of knowledge about the deadlines and requirements, or other factors. It also reduces the administrative burden on plans,” said Drs. Gehani and Donly, pointing out that of the beneficiaries automatically reenrolled during the 2019 open enrollment period, 15% were enrolled in a plan with zero premium after application of the Advance Premium Tax Credit.

“The ADA and AAPD oppose [reducing the tax credit] since even the most robust of educational programs as proposed by CMS would fail to capture the attention of all those affected, especially since low income consumers could be more difficult to reach. The risk of harm to those who would potentially lose their health insurance, and oral health benefits, far outweighs any perceived benefit.”

The comments also addressed:

Premium adjustment percentage
The ADA and AAPD are concerned that CMS’ proposal to change the way premium assistance is calculated would continue to increase premiums for exchange plans and decrease enrollment for consumers who receive the premium tax credit.

Maximum annual out-of-pocket limit on cost sharing
The proposed change in calculating the premium adjustment will also affect the maximum annual limitation on cost sharing. The new limitations will be $8,550 for self-only coverage, a $400 increase from 2019, and $17,100 for other than self-only coverage, an $800 increase from 2019. The ADA and AAPD believe that these increases in cost sharing will further increase the cost for consumers.

Quality rating system
The ADA and AAPD continue to encourage CMS and plan issuers to seek input from the Dental Quality Alliance as the Meaningful Measures Initiative is implemented into quality reporting and quality improvement programs. The DQA was established at the request of CMS, and as a multi-stakeholder coalition is well-positioned to collaborate, coordinate and lead efforts on quality measures.

Follow all of the ADA’s advocacy efforts at ADA.org/advocacy.