One of the biggest advantages that the Affordable Care Act (ACA) offers for people is the banning of refusal to cover and price gouging on the basis of pre-existing conditions. Supposedly, the law makes it illegal for insurance companies to refuse to cover someone who has a pre-existing condition or to deny coverage of the consequences of that condition.
But, apparently that’s not the case in Oregon, where healthcare companies are refusing to pay for dentures for newly covered Medicaid patients because of a rule that says people need to get dentures within 6 months of losing their teeth.
With the ACA’s expansion of Medicaid, which was opted into by Oregon and most other states, many people are getting medical coverage they previously couldn’t afford, all of it being paid for by the Federal government, through 2016, at which point it begins to slowly transition to the states paying their agreed-upon share of the Medicaid expenses.
The problem is that many of the newly covered people are finding they can’t get benefits they thought were part of their coverage, which, in Oregon, includes dentures. That’s because many of the people are in violation of the Oregon Health Authority’s rule that people have to get dentures within six months after they lose their teeth or else dentures won’t be covered.
The problem is that many of these people who are now looking for dentures couldn’t afford them when they didn’t have insurance. Although many people have appealed the decision, OHA seems determined to strictly enforce it.
There is currently a bill in the Oregon House of Representatives that would ban this practice. It would remove the time restriction and allow more frequent replacement of dentures. The bill has broad, bipartisan support, but it faces likely opposition to the people who would be paying from the dentures.
Coordinated Care Organizations (CCOs) are companies that have been formed to manage and provide care for people who were added to the rolls of Medicaid as a result of the expansion. These companies would likely oppose the expansion of denture benefits, as they opposed the expansion of wheelchair and similar benefits. The reason they would oppose the expansion is simple: it would come out of their profits.
CCOs are compensated on a flat fee basis for the people they insure. Cost of providing more care without a proportional increase would have to come out of CCOs’ profit. However, the cost in this case is relatively small. With 750-1000 people affected, and the plan only providing economy dentures valued at around $1000, the maximum cost of providing this service is likely about $1 million. Although that’s certainly significant, it’s not much compared to the nearly $180 million CCOs made in profit in just the first three quarters of 2014, according to their financial filings.
Let’s hope that the Oregon legislature does the right thing and helps these people get dentures they deserve as part of their regular coverage.
Solving Oregon’s denture problem won’t help to address the underlying reason why people can be treated in this way. The ACA and Medicaid continue to treat dental care and dental coverage as if it’s somehow different from the rest of the body, when, in reality oral health and overall health are intimately connected in many ways.
Until we correct this problem, people will continue to fall through the cracks and won’t get the care they need.
Dental Excellence of Blue Bell