Systemic Denti-Cal Problems Increase Financial Hardship for Older Adults
Comprehensive coverage for dental care is not widely available for elderly Californian citizens. Medicare, designed to cover older adults, does not pay for dental treatment unless within specific conditions met with hospital care. Denti-Cal, accessible through Medi-Cal, is the most viable alternative, but systemic financial issues and a lack of providers means the service is inadequate for patients’ needs. California’s Little Hoover Commission found serious deficiencies the program’s billing and administration, with patients waiting overly long periods for administrative processes and pre-authorizations, to the point where dental offices actively encouraged patients to forgo Denti-Cal. Reimbursement rates for Denti-Cal providers are the lowest in the US, with providers paid only a third of the national average pay of Medicaid dental providers. As a result, dental offices avoid Denti-Cal affiliation, leading to a shortage of providers and an increase in the recommendations for dental credit cards. The failings of the Denti-Cal system puts low-income older adults at great financial risk, as well as reducing access to oral health practitioners and lowering oral health rates.

Linda—a low-income older adult living in Los Angeles County—applied for a dental credit card after being advised to do so by her dentist. Her dentist’s office explained that, while she has dental coverage through Denti-Cal, it often takes a long time to get authorizations approved and it would be in her best interest to pay right now with the card and get reimbursed later. When Linda received her statement, it showed she owed over $2,000. Not only did she receive services that were not covered by her insurance, she also was charged for services that should have been covered by Denti-Cal but that were denied because her dentist’s office did not properly submit the claim to Denti-Cal. Unable to pay the $2,000 within the no-interest six month promotional period, Linda was hit with the balance plus six months of interest that accrued at 26.9%. Distraught, Linda contacted a legal advocate who is now working to dispute the charges and to rescind the credit card contract.

Unfortunately Linda’s story is not unique. Many older adults seeking dental services are counseled to take out high-interest credit cards to pay for their care even when the services they need are covered by their insurance. The systemic problems outlined below with the Denti-Cal program and overall delivery of oral health care in California create a space in which these types of predatory lending practices have an opportunity to thrive.

Comprehensive coverage is unavailable. Medicare, the primary insurance for older adults, does not pay for dental services (except in narrow instances in a hospital setting). Some Medicare Advantage plans offer dental coverage, but the benefits are typically limited and still require out-of-pocket spending. Most low-income older adults eligible for Medi-Cal have access to dental coverage through Denti-Cal. Unfortunately, Medi-Cal coverage has many gaps. Such critical dental procedures as gum treatment, partial dentures, and root canals on the back teeth remain uncovered. In many circumstances, there are further limitations even when a service is covered. For example, stainless steel and resin crowns are covered, but the more durable and natural looking porcelain crowns are not. Denti-Cal also has an annual cost cap of $1800, further limiting access.

The hodgepodge of covered versus non-covered services makes it difficult for older adults to make informed decisions about what treatment they should pursue and ascertain what costs they may ultimately incur.

Denti-Cal authorization and billing processes are cumbersome. In April 2016, California’s Little Hoover Commission released a comprehensive report detailing the extensive deficiencies in the Denti-Cal program with regard to billing and administrative processes. Providers report that submitting claims to Denti-Cal costs more in administrative time than the services for which they are seeking reimbursement. Obtaining authorizations for covered services is also overly burdensome. Unlike in the commercial market, Denti-Cal providers are required to submit pre-authorizations for routine restorative services and the authorization process itself is difficult to navigate. One provider stated that he had to hire a full-time employee to work solely on pre-authorizations and resubmissions of denied authorizations.

It is therefore not surprising that dental offices encourage their patients to circumvent Denti-Cal in the short term or forgo Denti-Cal entirely by taking out a dental credit card to receive more timely and comprehensive treatment.

Denti-Cal reimbursement rates are abysmally low. California’s reimbursement rates are lowest in the country. Denti-Cal providers are paid about one-third of the national average of what Medicaid dental providers are paid. Such low reimbursement rates combined with administrative costs associated with obtaining authorizations and submitting claims incentivize dental offices to seek out ways in which they can avoid these costs and obtain higher reimbursement.

Denti-Cal providers are scarce. With low reimbursement rates, high administrative costs, and barriers to enrolling, many dentists opt not to enroll in the Denti-Cal program at all. In fact, there are eleven counties where no Denti-Cal providers are available or none are willing to accept new patients. As a result, Denti-Cal enrollees have a hard time finding a dentist and end up seeking treatment with a provider who does not accept Denti-Cal. Because these low-income enrollees have no ability to pay upfront, they are counseled to apply for a dental credit card and make payments over time.

Denti-Cal needs to be fixed. These systemic problems in the Denti-Cal program not only limit access to oral health providers, reduce the quality of oral health services, and diminish overall health, but they also put older adults at an unacceptable financial risk. Low-income older adults struggle day-to-day to afford basic housing, food, transportation, and health care. Even a modest unexpected out-of-pocket expense for older adults can mean skipping meals or forgoing filling a prescription. When faced with dental bills totaling thousands of dollars with high interest rates and the threat of collection, they find themselves in an untenable position. California must act to fix the Denti-Cal program to ensure that older adults have affordable access to quality oral health benefits.

If you know someone who has taken out a credit card to pay for dental services and wants legal assistance, contact the Health Consumer Alliance Hotline at 888-804-3536.

They may be able to help with:

Filing a complaint with the Consumer Financial Protection Bureau

Disputing the validity of the credit card contract under California’s consumer protection laws

Negotiating a payment plan and/or reduction in the amount due

Beyond Lip Service is a Justice in Aging blog series featuring work to improve oral health for older adults, in California and across the nation.