Preventing Cost Shifting Within the Delivery of Dental Care

The Massachusetts Dental Society seeks to ensure that dental benefits companies do not unfairly shift costs to private-pay patients and dental practices by setting fees for services for which they do not pay providers. An Act Relative to Financial Services Contracts for Dental Benefits Corporations would prohibit dental benefits companies from unfairly shifting costs onto private-pay patients. 

The Issue

Under current Massachusetts law, dental benefits companies are able to limit the fees dentists can charge, even for the services for which the dental benefits companies do not actually reimburse, such as veneers, tooth whitening, or other cosmetic procedures. As a result of this unfair and unjustified price cap, the benefits companies force dentists to charge higher overall fees to private-pay patients who are, disproportionately, young people, the elderly, and workers whose employers do not offer dental plans.

Historically, dental benefits companies only set fees for services for which they provide payment. That is, if a patient requires a procedure that is not covered by his or her plan, the patient must pay the dentist’s full, usual, and customary fee paid by all other patients. The dental practice is thereby able to spread fixed costs across the entire patient population.

Policies that allow dental benefits companies to set fees for services for which they do not pay providers are also known as “non-covered services policies.” These policies set a cap on the amount that a participating dentist can bill a patient for services not covered under the plan, thus setting a maximum allowable fee on non-covered services. 

Allowing non-covered services policies forces dental providers to shift costs to other patients and increase fees for private-pay patients who pay out-of-pocket for care. Private payers are often elderly people or young adults with limited employment and sources of income, or low-income workers whose employers do not provide dental benefits. 

Private-pay patients suffer the greatest financial burdens of non-covered services policies. These individuals are forced to subsidize the care of other patients with dental plans to protect the bottom line of the dental benefits companies.


Legislative Solution

An Act Relative to Financial Services Contracts for Dental Benefits Corporations | H.1005/S.545

An Act Relative to Financial Services Contracts for Dental Benefits Corporations would:

  • Prohibit dental benefits companies from contractually setting fees for services for which they do not provide payment.
  • Ensure that no preferred provider arrangement with a health care provider who is a registered dentist would require the dentist to provide services to a covered person at a particular fee unless the services are covered services. “Covered services” means dental services for which reimbursement is available or would have been available had the patient not reached a contractual limitation, such as frequency limitations, annual maximums, etc.

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