Background Color:
 
Background Pattern:
Search

BREAKING NEWS: PPO DENTAL INSURANCE

InsuranceIconLeft

The TDA is aware of recent communications regarding certain dental insurance plans and is working to gather as much information as possible to fully understand the situation and discuss potential actions. The following provides basic information about the insurance plans being discussed.

First, one must understand how the McCarran Ferguson Act of 1945 affects the business of insurance in this country. In a general sense, the McCarran Ferguson Act exempts the business of insurance from federal law unless that law specifically says that it regulates the business of insurance, and this includes federal anti-trust laws to some extent. The Act essentially makes state law the primary regulator of insurance, and allows insurance companies to share information on insurance losses for the purpose of setting prices for their products. The ADA has tried for many years to repeal the McCarran Ferguson Act, with little to show for the efforts until 2017. In March 2017, as part of a broader health insurance reform act, the US House of Representatives approved repeal of the limited McCarran-Ferguson antitrust exemption for health insurers by a vote of 416-7. But the legislation has stalled in the Senate.

Second, there are three types of insurance at issue here: EPO, HMO and PPO. An exclusive provider organization (or EPO) plan is a health plan with a closed provider network offered by an insurance company. An EPO plan is similar to a health maintenance organization (HMO) plan where only services by network providers are covered, with the exception of emergency services that may be provided by out-of-network providers when no in-network providers are available.

EPO plans were created in Texas in 2011 as a result of insurance companies citing the need to offer lower cost health plan options to employers and consumers. Under Texas insurance law, an EPO plan is not required to compensate a non-preferred provider (out-of-network) for services rendered for non-emergency care.

A preferred provider organization (PPO) plan is a health plan in which an insurer provides levels of coverage that differ according to whether the insured person uses a preferred provider (in-network) or non-preferred provider. Texas law mandates that state-regulated insurance companies pay contracted dentists and non-contracted dentist the same reimbursement. The TDA pursued this law many years ago and successfully advocated passage of it. This protection gives the patient the ability to see the dentist of his/her choice. This unique state insurance provision does not apply to EPO plans. Moreover, the Employee Retirement Income Security Act of 1974 (ERISA) may affect whether this state insurance provision applies to self-insured employer-sponsored health plans governed by ERISA.

The TDA is fully mobilized on this issue; however, factual information is scarce. If any dentist has information to share, please do so by contacting Diane Rhodes, diane@tda.org. We will continue working with all dentists to gather information in an effort to ensure all Texas dental patients have a choice when it comes to their oral health care.