Expanded Covered California Dental Coverage Could Pose Access Problems

OAKLAND, CA - JULY 9: Dentist Edward Rothman performs a dental examination on eleven-year-old Ahmani Staten of Oakland, California at the pediatric dental clinic of Children?s Hospital Oakland (CHO) July 9, 2003 in Oakland, California. The dental clinic that serves critical children was facing closure due to budget cuts until the Oakland-based La Clinica de La Raza stepped in with plans to take over operational and financial management. La Clinica de La Raza is a non-profit corporation of community health centers dedicated to improving the health of East Bay community residents since 1971. (Photo by Justin Sullivan/Getty Images)
While children’s advocates applaud expanding Covered California’s dental coverage, they caution that there already aren’t enough pediatric dentists in the state. Stock photo/Getty Images

Beginning Jan. 1, all individual Covered California health plans will include dental coverage for children in the family 18 and younger, a move that state officials hope will result in tens of thousands of kids getting oral health care.

While children’s advocates applaud expanding the coverage, they caution that there already aren’t enough pediatric dentists in the state. They say certain dentists may decide not to accept the Covered California insurance, leaving some of the newly insured without access. Or, dentists might decide to accept the Covered California plans but stop seeing Denti-Cal patients because the low-income health program reimburses dentists at a lower rate than private insurers. Denti-Cal is California’s Medicaid dental program.

Under Covered California the reimbursements rates are likely to be higher than the Denti-Cal rates, but “we just don’t know if that means some dentists might drop Denti-Cal patients for newly insured ones, or how many dentists will even accept the Covered California rates,” said Kathleen Hamilton, director of governmental affairs in Sacramento for The Children’s Partnership, who has had her own struggles finding dentists who take Denti-Cal for her two foster sons.

The need for increased dental coverage is massive in California. According to the American Academy of Pediatric Dentistry, tooth decay is the most common health problem for kids in the U.S., with four times as many cases as asthma.

A 2013 report by The Children’s Partnership found that in 2007 there were 87,000 emergency room visits for preventable tooth problems in kids, and close to 900,000 missed school days for dental-related problems. And according to children’s health advocacy group Children Now, based in Oakland, 37 percent of 2 and 3 year olds in California have never been to the dentist, and only one in three children ages 0-3, enrolled in Denti-Cal have seen a dentist. The American Academy of Pediatric Dentistry recommends that children have a dental visit by the time their first tooth appears or no later than their first birthday.

Sign ups for Covered California begin Nov. 15 and the coverage will take effect Jan. 1. All individual health plans purchased through Covered California will have embedded dental plans for children that require no additional premium. Last year dental coverage for kids was offered only as a standalone plan with a separate premium.

Each Covered California health insurer is contracting with dental providers who agree to accept the insurer’s reimbursement rates, which have not yet been announced. Deductibles and copays will apply in most cases.

Denti-Cal is an important harbinger for how well kids teeth might fare under the new Covered California dental coverage, advocates say. Like the new Covered California plans, dental care is embedded in Medi-Cal plans, but a 2007 survey by the UCLA Center for Health Policy Research found that close to 20 percent of families enrolled in Medi-Cal didn’t know that they had dental coverage.

“We will need to educate parents who buy the health plans that they now have the coverage for their kids and how to access that dental care,” said Eileen Espejo, director of media and health policy for Children Now.

Recent surveys by Children Now found that by kindergarten, over half of children in California have already experienced dental decay and 28 percent have untreated decay. Children who reported having recent tooth pain were four times more likely to have low grades.

Many kids enrolled in Denti-Cal already have trouble finding a dentist who will accept the low reimbursement rates, which hover at about 30 percent of what most dentists charge, according to advocates.

The Children’s Partnership report found that only about 30 percent of dentists take Denti-Cal patients and most take only a few patients. Twenty counties, many of them low-income, have no pediatric dentists at all, which makes a trip to the dentist especially arduous for families with no car and who are paid by the hour, but must take off time from work for the trip.

Federally qualified health centers and community clinics try to offer dental appointments as best they can, but advocates say they aren’t able to accommodate everyone seeking care.

The 2013 Children’s Partnership Report included the story of a 6-year-old who had a dental assessment at school under the federal Women’s Infant and Children program that found a small spot on a back molar. Her mother made repeated calls to the area dentist who took Denti-Cal but wasn’t able to get an appointment until one day when the child’s pain was so intense, her mother demanded that a dentist see her. The dentist did that day and what was once a cavity was now a tooth decayed and needing extraction.

Stephanie Ashlock, 27, of Merced County, whose three kids are covered under Denti-Cal, took each of her children to the dentist for a checkup last year, but saw a different dentist for each child because each time she tried to make the next appointment, she was told the dentist no longer accepted Denti-Cal patients.

Covered California is already anticipating the likelihood that some dentists won’t accept the embedded plans. Later in 2015, the marketplace will introduce a standalone family dental plan that will cover adults, as well as kids whose parents want them seen by dentists who don’t accept the embedded plan coverage. The family plans will have a separate premium that has not yet been announced.

There’s no question that the embedded dental plans for next year’s coverage year are an important start. But dental health experts say much more is needed in order to improve dental health for all of California’s kids.

What’s desperately needed is a state oral health director in the California Department of Public Health “to build up the state dental health plan,” said Lindsey Robinson, immediate past president of the California Dental Association. Robinson said that person should be a licensed dentist and charged with producing a “burden of disease report” to demine where the unmet needs are and to create oral health needs reports for the state. The reports then could be used to apply for federal grants and expand services “beyond what the state has been able to offer.”

Robinson and other dentists are also concerned that some California clinics and hospitals that treat special needs children and adults have recently decided to close or stop certain programs. Sutter Hospital in Sacramento was the last hospital with such as clinic in the region and had planned to close during the summer, but so far has remained open. Sutter executives have said that to remain viable, the Denti-Cal reimbursement rates has to increase and some of the low-income patients being seen at the hospital need get care at other facilities.

A ray of hope came in late September when Gov. Jerry Brown signed legislation to expand virtual dentistry services in the state beginning Jan 1. Dental hygienists and technicians will be able to perform more work, such as installing temporary fillings, after consulting with a dentist remotely. Patients will be referred to a dentist for more complicated procedures.

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