By Christine Nathe, RDH, MS
Since public funding systems continue to change, it's important for dental hygienists to stay current with public funding infrastructure. Public funding includes Medicare, Medicaid, Children's Health Insurance Program (CHIP), and the Basic Health Program (which operates in only two states). Together, these programs provide coverage for over 100 million people in the United States. This is a considerable amount of people, so it's well worth the time of dental hygienists to understand all programs.
The Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for administering public funding derived from tax dollars. Probably most recognizable to Americans is Medicare. Interestingly, Medicare and Medicaid were signed in 1965 as Title XVIII and XIX of the Social Security Act.
Medicare, which is operated by the federal government, primarily funds medical care, not dental care, for people age 65 or older, and in some instances people who have disabilities. In specific cases, Medicare may provide reimbursement for dental procedures carried out in the hospital on elderly people or individuals who have disabilities, but generally it does not fund dental care (see related sidebar).
Medicaid is the program that traditionally funds dental care to the low-income population. It is administered by the states but is also partially funded by the federal government. Medicaid insurance can be paid to dentists and, in some states, dental hygienists in private practice or community clinical settings. In many states, private agencies operate the state Medicaid coverage. Because of the freedom of states to apply the federal money in different ways, Medicaid dental coverage differs from state to state.
Some states offer adult dental benefits and others do not. Some provide coverage only to children under the age of 21, which is a mandatory requirement for use of federal money. Others choose to insure all low-income individuals regardless of age.
Medicare is a health insurance program for people age 65 or older, under age 65 with certain disabilities, and of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). Medicare has several components:
- Part A hospital insurance-Most people do not pay a premium for Part A because they or a spouse paid for it through their payroll taxes while working. Medicare Part A (hospital insurance) helps cover inpatient care in hospitals, including critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to receive these benefits.
- Part B medical insurance-Most people pay a monthly premium for Part B. Medicare Part B (medical insurance) helps cover doctors' services and outpatient care. It also covers some medical services that Part A doesn't cover, such as the services of physical and occupational therapists and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
- Prescription drug coverage-Most people pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage became available to everyone with Medicare. This coverage may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance, and private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if beneficiaries decide not to enroll in a drug plan when they are first eligible, they can pay a penalty if they choose to join later.
Beginning in 2014, the Affordable Care Act gave states the authority to expand Medicaid eligibility to individuals under age 65 in families with incomes below 133% of the federal poverty level. This meant that people who have higher incomes than what was traditionally funded would be eligible. In 2010, 22% of the population was enrolled in the Medicaid program at some point.
CHIP was enacted in 1997 and provides federal matching funds to states to provide health coverage to children in families with incomes too high to qualify for Medicaid. Nearly every state provides coverage for children up to at least 200% of the federal poverty level since CHIP has been in operation. This funding mechanism was created to make sure all children had coverage.
Dental hygienists should be aware of federal programs and changes to public funded dental care, specifically dental coverage that might be available. A great way to begin learning is to search your state's Medicaid website. RDH
CHRISTINE NATHE, RDH, MS, is director at the University of New Mexico, Division of Dental Hygiene, in Albuquerque, N.M. She is also the author of "Dental Public Health Research" (www.pearsonhighered.com/educator), which is in its third edition with Pearson. She can be reached at [email protected] or (505) 272-8147.