A few weeks ago, oral surgeon Dr. Frederick A. Hartman said he was treating a patient who thought he could afford the dentures he needed because they would be covered by his insurance plan.
But all the patient’s benefits for the year were maxed out just on preparing his jaw for the dentures.
This meant he would have to wait a painful six months for his coverage to reset in the new year before he could get his dentures.
“He’s basically with no teeth for six months,” said Hartman, who is chairman of the Rhode Island Dental Association.
This is just one of many patients Hartman sees who have insurance coverage but are still not able to afford the care they need. As a result, some patients spread necessary treatments over several years, causing pain and risking complications.
In other cases, patients opt to forgo the costs for anesthesia and endure a painful procedure.
It’s an issue across Rhode Island, and Hartman says some dental offices have stopped accepting some insurance plans altogether because of frustrations over coverage limitations.
But Hartman says legislation known as the Fair Share for Dental Care Act, which has been introduced in this year’s General Assembly, could help more dental patients get the coverage they need.
Rep. Joseph M. McNamara, D-Warwick, and Sen. Hannah M. Gallo, D-Cranston, have introduced companion bills that would require dental insurance companies to spend at least 85% of Rhode Islanders’ dental premiums on patient care instead of administrative costs.
This is also known as a dental loss ratio. Under the proposed measure, if insurers fail to meet the 85% ratio, they must refund the difference. Also, carriers would be required to submit annual information about current and projected medical loss ratios.
“It’s really a bill that’s centered on patients,” Hartman said. “This bill would hopefully make it more affordable to get good care.”
McNamara says the 85% medical loss ratio matches the federal Affordable Care Act, which requires medical insurance companies to spend at least 80%-85% of patients’ premiums on care and quality improvements.
While there is no federal requirement for insurance, the American Dental Association estimates around 45% of dental care is paid for with out-of-pocket expenses, compared with 16.6% for medical costs.
Similar measures have been introduced and implemented in several states. In 2022, Massachusetts voters passed a bond referendum that requires dental insurers to spend at least 83% of their premiums on care.
McNamara says he proposed the bill last year, but it didn’t make it out of committee. This year, he’s more optimistic. McNamara says the legislation has received support from both political parties and the state dental association.
“The end result of this we would like to see is the quality and scope of dental care and oral health expanded,” McNamara said.
But some dental insurers disagree, saying an 85% medical loss ratio would cut into insurers’ ability to cover administrative expenses to the point they will likely have to increase patient premiums.
“It just means fewer affordable plans are going to be available for small businesses and individuals seeking dental insurance – that’s an immediate consequence of this,” said Michelle Muscatello, Delta Dental of Rhode Island vice president of communications and public affairs.
So far, multiple insurers have either reduced or eliminated the small-group market in Massachusetts since the state implemented a medical loss ratio at the beginning of this year, said James Kinney, Delta Dental vice president of sales and business relations. As a result, Kinney says researchers project rates will rise around 38% in Massachusetts and 42% in Rhode Island if the bill is passed.
“What we’re seeing in Massachusetts is devastating to the market and we’re really afraid that could happen here,” Kinney said.
Instead, Kinney and Muscatello say Delta Dental is backing a separate bill introduced by Rep. Brandon T. Voas, D-Cumberland, that is a more local version of the model legislation released by the National Council of Insurance Legislators.
The bill would require dental insurers to report their medical loss ratio information to the R.I. Office of the Health Insurance Commissioner for the years 2025 through 2027. At the end of that period, OHIC would review the data and give recommendations for how to best proceed with medical loss ratio requirements.
“We’re really not opposed to a [dental loss ratio], we just feel it needs to be studied,” Kinney said. “The number that might be right for us might be different for other insurers … it really should be the OHIC office choosing what that number should be.”
