ODA ADVOCACY EFFORTS RESULT IN INSURANCE REFORM
The 135th General Assembly enacted legislation, Senate Bill 40, in 2024 that adds common sense fairness back to the dental insurance system. This new law prohibits dental insurance companies from dictating fees for services that the insurers do not even cover. Any new contracts entered into from Jan. 1, 2025 on, must be compliant with the new non-covered services law.
“With Ohio having been the 43rd state (2024) to pass non-covered services legislation it is gratifying to see yet another obstacle removed from the dentist-patient relationship,” said ODA President Dr. Hal Jeter. “By prohibiting insurance carriers from invoking an arbitrary restriction on services for which they have no financial responsibility dentists are able to more readily provide their patients with the treatment they desire and deserve.”
Benefits of the new law include:
- Dental insurance companies are no longer interfering with the dentist-patient relationship on services the dental insurers do not even cover.
- Dental patients now have continuity of care that they desire for non-covered services.
- Ohio continues to have a robust and competitive dental insurance marketplace.
- There has been no spike in dental fees as a result of passage of SB 40.
Ohio’ s non-covered services reform legislation was modelled after a National Council of Insurance Legislators (NCOIL) model act that has now been passed in 43 states.
Under the new law, anything that does not meet the definition of a covered dental service is considered a non-covered service. Covered dental services are defined in the new law (ORC 3963.01) as “dental care services for which reimbursement is available under an enrollee’s health care contract, or for which a reimbursement would be available but for the application of contractual limitations, such as a deductible, copayment, coinsurance, waiting period, annual or lifetime maximum, frequency limitation, alternative benefit payment, or any other limitation.”
Annual maximums, lifetime maximums, frequency of service limitations, least expensive alternative treatment are all examples of contractual limitations that are unchanged by the new law and therefore require contracted dentists to honor the insurance company’s allowed fee as the maximum amount they may collect for the service(s) in question.
The new law mandates the dentist provide to the enrollee/patient who is seeking non-covered dental services pricing and reimbursement information, including: 1) estimated fee or discounted price suggested by the patient’s insurance company for the non-covered service, 2) estimated fee charged by the dentist for the non-covered service, 3) amount the dentist expects to be reimbursed by the insurance company for the non-covered service (which is $0 since it is not a covered service) and 4) estimated pricing and reimbursement information for any covered services that are also expected to be provided during the patient’s visit.
The dental office must also post in a conspicuous place a notice stating: “IMPORTANT: This dental care provider does not accept the fee schedule set by your insurer for dental care services that are not covered benefits under your plan and instead charges his or her normal fee for those services. This dental care provider will provide you with an estimated cost for each noncovered service.” ODA members may obtain a table tent card containing this notice by contacting the ODA at (614) 486-2700 or (800) 282-1526 or going to https://www.oda.org/member-center/resources/printable-office-resources/.
At this year’s ODA Day at the Statehouse, attendees thanked their legislators for enacting this commonsense reform into law for Ohio.
“It cannot be overstated that this legislative achievement could only have been attained by the determined diligence of the ODA’s advocacy efforts,” Jeter said. “In addition to our lobbying team the number of members who personally took time away from their offices, wrote letters and called their legislators, and those who took part in Day at the Statehouse were integral in forging the relationships that resulted in the passage of this and other legislation essential to our practices and our patients.”
Attendees also educated lawmakers about how dental insurance works and explained the differences between health insurance and dental insurance.
- Health plans generally encompass a wider range of medical services from hospitals, physicians, labs, and pharmacies with cost-sharing through deductibles, coinsurance and copays.
- Dental plans typically cover a limited range of services such as routine oral exams, cleanings, X-rays, fillings, crowns, and tooth extractions, often subject to a deductible and available at discounted rates through in-network dentists. Cosmetic procedures are usually not a covered benefit.
- Dental benefits focus on prevention and basic services whereas health insurance covers a much broader array of services from many different care providers and also provides coverage for catastrophic health care events which generally do not occur in dental care.
- It is important to understand that dental benefits are typically purchased with the expectation of being used regularly, offering predictable costs for patients. In contrast, health/medical insurance is often chosen as protection against major, unexpected health events, with costs that are less predictable.
- Health insurance usually includes an annual out-of-pocket maximum designed to limit patient costs after the patient has met any applicable deductibles.
- Dental plans are designed to have the patients financially participate in the cost of care and usually do not include an out-of-pocket maximum so there is no cap on the patient’s potential out of pocket obligation in a worst-case scenario.
- Most dental benefit plans include annual maximum benefits which protect the dental insurers from having to pay any more than the maximum (typically between $1,000 and $2,000) regardless of the cost of dental treatment necessary. These annual maximums have been flat for decades even though inflation and costs have increased over time. As a result of this, patients’ dental benefits are actually covering less care today than in the past.
The ODA will continue to monitor the dental insurance landscape and advocate on behalf of the profession of dentistry for common sense dental insurance reforms. Stay tuned to the “ODA Today” to learn more about future advocacy efforts.
