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.