A study published in The Journal of the American Dental Association put forward prospective plans for Medicare to add an adult dental benefit.
The study underscored five important aspects of implementing any dental benefit: The ADA should be included in the process; there needs to be bipartisan legislative outreach; coverage should be similar to existing oral healthcare coverage plans; draw upon the lessons from implementing a dental benefit into Medicaid; and learn from Medicare Advantage dental plans.
The authors of the study compare two potential variants for implementing a Medicare dental benefit that have been discussed in the industry.
Variant 1: Medicare Plan B model
- This mandatory plan would be similar to medical coverage plans and beneficiaries would pay an added premium for oral health benefits.
- The plan would provide 80% payment for covered services and have no limit or maximum.
- The variant could lead to high plan costs, premiums and subsidies with low reimbursement rates for dentists, necessitating substantial government funding due to the lack of cost-containment measures.
- The plan would likely be preferred by health policy and public health advocates.
Variant 2: PPO model
- This plan would take aspects of existing preferred provider organization plans and have the option to be mandatory or elective.
- Beneficiaries would receive dental coverage for an added premium and the plan would cover services as a percentage of usual and customary rates or fees .
- This plan has cost-containment measures, including co-pays and annual maximums.
- Reimbursement rates would differ based on the dental service provided.
- As this model is similar to what dentists and dental insurers are more used to, there would be less of an administrative burden compared to variant 1.
- Oral healthcare professionals and providers would likely prefer this plan instead of variant 1.
The study combines ideas from both variants to create two hybrid models.
Hybrid model 1
- This model would be mandatory for Medicare beneficiaries.
- A designated set of procedures would be covered at 80% of a discounted UCR and 20% patient co-pay.
- All Medicare enrollees would receive benefits from this model.
Hybrid model 2
- Other dental procedures would be covered as a percentage of a discounted UCR and various dental services would be reimbursed differently.
- Hybrid 2 would not be mandatory but would be available to all Medicare beneficiaries for an added premium.
- This model could have low, medium and high options, each with different prices and covered services.
Read the full study here.