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Inequities and Confusions with Dental Insurance

By Atish Shah, DMD, MS, MPH

June 2023
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In the fall and winter months, dental offices are typically packed with patients bringing their families in for dental care. This rise in patients towards the end of the year in most instances can be attributed to dental insurance[1]. With benefits expiring at the end of the year, patients schedule their last-minute exams and cleaning appointments. December is widely observed to exceed the averages of practice gross production and number of patients seen[1]. According to the National Association of Dental Plans, only 2.8% of people with PPO plans make use of their full benefits before they expire by year’s end[2]. Although it is advantageous for policyholders to utilize their dental benefits the data shows an astounding 38% of adults in Arizona did not report a dental visit in 2018[3]. This is primarily due to the unwillingness to place importance on oral health, coupled with a lack of dental insurance and high costs. If patient’s benefits are renewed or yearly maximum are depleted, they must then wait to receive treatment when their benefits are fresh in the new year or pay out of pocket. This often comes at a steep price for patients requiring extensive procedures such as root canals, crowns, and surgical extractions. 


Arizona’s Insufficient Dental Care

Arizona has consistently ranked lower than the national average for dental visits since the year 2000[3]. There is a great need in improving the utilization of dental benefits which will encourage patients to receive routine dental care. In response, this will promote oral health care and overall systemic health. A surprise to many, the oral cavity is referred to as the window into the general overall health of a patient[4]. Associations have been established between oral health and systemic diseases such as cardiovascular disease, Alzheimer’s disease, dementia, obesity, and numerous cancers[5].


It has become apparent that oral and systemic diseases share multiple risk factors. A study by Stearns et al., showed how preventive oral health programs are cost-effective and reduce additional payments for hospital visits relative to systemic health conditions[6]. However, oral disease prevention programs are the last resort when the decision-makers consider the allocation of healthcare resources. This has directly led to a disparity between medical and dental integration. Dentistry is often seen as a cosmetic need whereas medical care is perceived as a necessity. It is further proved by a survey conducted by CareQuest Institute for Oral Health that found 77 million adults in the U.S. do not have dental insurance[7].


Impact of Insurance

A lack of dental insurance can have a negative impact on the number of dental visits[8]. Approximately, one-third of adults and 10 percent of children have no form of dental coverage benefits[9]. Nationally, only 50.2% of adults aged 18-64, had dental coverage[8]. These rates are astonishingly low for how far we have come from the advent of American dental insurance in 1954 to now[10]. The direct correlation between oral health and systemic health is significant, therefore patient’s utilization of dental benefits should be higher than what we are currently seeing.


Unlike most health insurance policies, there are annual maximums in dental coverage which have largely remained unchanged for decades[11]. For example, the dental insurance average annual maximum benefits have been about $1,000-$1,5000 for the past 70 years[11]. This amount puts a limit on patients because they may be less reluctant to pay out of pocket for their higher costing procedures after they have used up their annual maximum. Majority of policies will offer an annual maximum of $1,500 that can easily be met if you need a crown, root canal, or oral surgery[17]. Anything after that comes out of pocket. On the other hand, the annual maximum serves as an incentive for patients to receive routine dental care to prevent minor issues from compounding and to avoid the expected treatment costs from exceeding the cost of the plan[12]. 

Arizona Medicaid

There is a glaring gap in dental coverage for adults enrolled in Arizona Medicaid. Their only access to oral health care is an annual limit of $1,000 for emergency dental services[15]. As per the AZ Medicaid policy manual, a dental emergency is an acute disorder of oral health resulting in severe pain or infection[15]. No basic restorative care such as fillings are covered under Arizona Health Care Cost Containment System (AHCCCS). Expanding access to oral healthcare is essential in reducing economic inequities, improving overall systemic health, and bridging the racial justice gap[14].


Increasing Medicaid’s dental coverage would result in far fewer emergency department (ED) visits and reduce the cost of care. In Arizona, nearly 80% of ED visits for non-traumatic dental conditions were made by adults enrolled in Medicaid, whereas the national average of ED visits was 70%[15]. The costs were also higher for adults visiting the ED for dental problems in Arizona compared to a national level15. An average ED visit cost $1,520 for all ages and insurance groups, whereas in Arizona that charge is $2,251[15]. A similar visit to a dental office or clinic for pain would cost anywhere between $90-$200[15]. This reiterates the thought that routine dental care is extremely important and should be included in Arizona Medicaid. Adult patients enrolled in AHCCCS should not be forced to wait until their situation becomes unbearable that they visit the emergency department for easily preventable oral health issues. The higher costs alone can be a determining factor to include routine dental care in Medicaid.


Confusion with Insurance

There is also an issue with health literacy and the understanding of dental insurance along with its confusing terms. As per a recent Forbes Advisor study, 77% of Americans were unable to correctly define basic health insurance terms like coinsurance, copayment, and deductible[16]. Navigating through dental insurance is not an easy task for patients or providers alike. The intricacies of insurance are widely displayed in the front office of any clinic where patients have a difficult time understanding what benefits they truly have and what procedures are covered. Additionally, with inflation continuing to rise, it is even more crucial for patients to understand their policies so they can maximize all their benefits. If a plan requires a monthly premium payment, it is best advised to put it to use and schedule an appointment as majority of all plans cover 100% of preventive visits according to Delta Dental AZ[17].  


Effects of Inflation

Rising costs of goods and services have found its way into both health and dental insurance. As of 2022, the average premium for health insurance has increased by 18% since 2017[18]. Medical coverage has become costlier due to a 5% increase in the average cost of healthcare in the past 12 months. This rise includes escalating prescription drug prices, healthcare service costs, and administrative expenses[19]. These pains are also seen in dentistry. Inflation has risen 7.7% over the last 12 months[19] and the economic impacts have greatly affected dentistry. ADA president Cesar R. Sabates D.D.S said, "eight out of 10 dentists reported issuing pay raises for their dental hygienists and dental assistants within the past year”. Dental costs have also risen due to inflation, which has led to an increase in materials and salaries[20]. An increase in costs places a strain on dental practices and patients alike. Another area of concern is the stagnant annual maximum amounts of dental benefit plans, which should be adjusted to be more practical and aligned with the increasing consumer price index[11].


The average monthly premium for dental insurance in the state of Arizona has seen minor increases as it is $31.17 as of 2022 and was $23.98 in 2011[21]. Insurance companies can maintain lower reimbursement rates to dentists by keeping premiums low[22]. Essentially, this business strategy allows the large insurance corporations to retain more of the profits.


Increasing dentist reimbursement rates would result in higher monthly premiums, as insurance companies would pass on that cost to the policyholders. One potential solution to this would involve insurance companies reducing their profit margins, enabling lower monthly premiums and higher reimbursement rates for dentists. Recently, the President and CEO of Delta Dental AZ, Michael Jones, has addressed the concerns of low reimbursement rates and has assured dentists there will be a moderate increase in the rates[23].


The importance of insurance weighs heavily on all aspects of medical and dental care. Arizona has seen the effects through its below national average dental visits, the gap in Medicaid dental coverage, and lower reimbursement rates for providers. Understanding the world of health and dental insurance has never been more important than it is now for providers and patients. There are limitations with dental insurance that are causing harm to those who are unable to obtain basic oral health care in Arizona. The state of Arizona needs to find a suitable solution to improve access to oral healthcare and promote overall health equity.

About the Author:

Atish Shah, DMD, MS, MPH, completed his Bachelor's degree in Economics and worked in corporate finance. He went on to complete his Masters degree in Science, where he discovered a passion for dentistry. Atish then earned DMD and MPH degrees from the Arizona School of Dentistry and Oral Health at A.T. Still University. Atish's interests included digital dentistry, public health, and healthcare economics. In his free time, Atish enjoys spending time with family and friends, watching sports, and playing golf. 


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