May 2020 Volume LV Number 3


Are You Ready to be a Navigator?

March 2014 Volume L Number 2

 The four years since the passage of the Affordable Care Act (ACA) have produced concern, optimism, market positioning and—frankly—corporate cronyism the likes of which we have not seen in decades. The largest expansion of government programming since the Great Society in the 1960s, the ACA places one-sixth of our economy on everyone's to-do list. Now we all must secure a health plan commensurate with our family's needs, balanced with an expansive list of essential benefits. This is an enormously complex undertaking: accessing the system, sharing confidential information on a less-than-secure website, and choosing from a myriad options, all before finally paying the annual premium. Did anyone else hear you can keep your doctor?

 In the past few months, the Academy has held an insightful course on the ACA and dedicated a portion of the Behavior Management Symposium to its impact on the delivery of dental services.


For those who did not attend these presentations on the ACA, I can characterize the plan as complex, illogical, and so tangled by details that only a rocket scientist—or possibly a pediatric dentist— can understand them.


With potentially millions of children becoming newly insured, the stakes are high for families to navigate the numerous options both in and out of state exchanges. Allow me an example to make my point.


With the various dental plan purchase options within and outside the exchanges including stand alone, bundled and embedded, it has become clear that increasingly—and, yes, ominously—dental plans will migrate from being a model of mostly stand-alones to an embedded plan along with a medical policy. On the face of it, it appears logical: consumers purchasing a single family plan from one carrier won't need to fuss with multiple plans or carriers, and premiums for the dental portion are relatively cheap. Here's the rub: embedded plans are designed to require that a universal deductible (which includes both the medical and dental plans) will need to be satisfied before a single dollar is paid to cover dental services.


There may be variance allowing some preventive services to be covered depending on if the plan is bronze, silver or gold; however, the general principle will remain. Let me repeat: Embedded plans can potentially require that a $2,000, $3,000 or $5,000 deductible is met before a single dollar is paid to a dental provider from the plan.


It is my opinion that as confused as you may be by my brief example of an embedded plan, your patients will be coming to your offices without the remotest idea that their seemingly innocent and well-intentional purchase of a health plan may well place them out of any insurance coverage for dental benefits. More importantly your patients will have so many potential variances of plan design coming from a state exchange that you—yes, you!—will need to serve as an ombudsman to your families that may find themselves in difficult positions.


My advice is that you begin to educate your front office staff as you gain a basic understanding of what's in your market, because I fear that an unintended consequence of these complexities in the ACA will be to make you a target for understandably frustrated parents and caregivers.


This, of course, doesn't even speak to whether you may be in any one or more plan networks in the marketplace that probably have not contacted you yet to confirm your participation as a network provider. Be patient and deliberate—the AAPD will be working diligently through all these uncertainties to support all of you our members so that you can continue to provide the best care in the world to your patients. That is a promise.

Did You Miss the ACA Conference? 


Visit the AAPD Education Passport at and gain access to the ACA Conference presentations, audio content, handouts, and earn continuing education credits!