DENTAL SERVICES. Information on Coverage, Payments, and Fee Variation

Transcription

1 Unit Stats Govrnmnt Aountability Offi Rport to th Chairman, Subommitt on Primary Halth an Aging, Committ on Halth, Euation, Labor, an Pnsions, U.S. Snat Sptmbr 2013 DENTAL SERVICES Information on Covrag, Paymnts, an F Variation GAO

2 Sptmbr 2013 DENTAL SERVICES Information on Covrag, Paymnts, an F Variation Highlights of GAO , a rport to th Chairman, Subommitt on Primary Halth an Aging, Committ on Halth, Euation, Labor, an Pnsions, U.S. Snat Why GAO Di This Stuy High rats of ntal isas rmain prvalnt aross th nation, spially in vulnrabl an unrsrv populations. Aoring to national survys, 42 prnt of aults with tooth or mouth problms i not s a ntist in 2008 baus thy i not hav ntal insuran or oul not affor th out-of-pokt paymnts, an in 2011, 4 million hilrn i not obtain n ntal ar baus thir familis oul not affor it. In 2011, th Institut of Miin rport that thr is strong vin that ntal ovrag is positivly ti to ass to an us of oral halth ar. For familis without ntal ovrag, frally fun halth ntrs may offr an afforabl ntal ar option. Halth ntrs ar rquir to offr sliing f shuls with isounts of up to 100 prnt for many low-inom patints. GAO was ask to xamin ntal srvis in th Unit Stats. This rport sribs (1) trns in ovrag for, an us of, ntal srvis; (2) trns in paymnts by iniviuals an othr payrs for ntal srvis; an (3) th xtnt to whih ntal fs vary btwn an within slt ommunitis aross th nation. To o this work, GAO xamin HHS national halth survy ata an national ntal xpnitur stimats, ntal insuran laims ata, an halth ntr ntal fs in 18 slt ommunitis (bas on nsus rgion, population, an ntal laims volum). GAO also intrviw HHS offiials an aami xprts. HHS provi thnial ommnts on a raft of this rport, whih wr inorporat as appropriat. Viw GAO For mor information, ontat Kathrin Iritani at (202) or iritanik@gao.gov. What GAO Foun Ovrall, trns in ntal ovrag show littl hang from 1996 to 2010 aroun 62 prnt of iniviuals ha ovrag. Th prntag of th population with privat ntal ovrag ras from 53 to 50 prnt (s fig.). Dntal ovrag through Miai or th Stat Chilrn s Halth Insuran Program (CHIP), whih was stablish in 1997, ros from 9 to 13 prnt. Th inras was u primarily to an inras in th numbr of hilrn ovr by ths fral-stat halth programs with manat piatri ntal ovrag. Iniviuals with no ntal ovrag ras from 28 to 25 prnt, an ovrag for 10 to 12 prnt of th population was unknown. Us of ntal srvis th prntag of iniviuals who ha at last on ntal visit also rmain rlativly unhang at aroun 40 prnt from 1996 to Miai an CHIP bnfiiaris, hilrn in partiular, show inrass in th us of ntal srvis (from 28 to 37 prnt), but still visit th ntist lss oftn than privatly insur hilrn (58 prnt in 2010). Dntal Covrag Status, 1996 an 2010 Not: For 2010, Miai inlu hilrn in th Stat Chilrn s Halth Insuran Program. GAO s analysis show that avrag annual ntal paymnts th total amount pai out of pokt by iniviuals an by othr payrs inras 26 prnt, inflation-ajust, from $520 in 1996 to $653 in Avrag annual out-ofpokt paymnts inras 21 prnt, from $242 to $294, for iniviuals with privat insuran an 32 prnt, from $392 to $518, for iniviuals with no ntal ovrag. Dntal fs harg by loal ntists an halth ntrs vari wily. For 8 of 24 ommon prours GAO xamin, rport uppr-n fs (th 95 th prntil of th rang in loal ntist fs) wr at last oubl th mipoint fs (th 50 th prntil of th rang in loal ntist fs) in svral ommunitis. For xampl, in Miami, Floria, th uppr-n f of $150 for a prioi oral xamination was mor than twi th mipoint ntal f of $62. Dntal fs also vari btwn loal ntists billing privat insurrs an halth ntrs srving rsints of th sam ommunity. In gnral, most halth ntrs in GAO s rviw offr a 100 prnt isount rsulting in no f to th lowst-inom patints for many, but not all, ntal srvis. Unit Stats Govrnmnt Aountability Offi

3 Contnts Lttr 1 Bakgroun 6 National Survy Data Show That Rats of Dntal Covrag an Us of Dntal Srvis Rmain Gnrally Unhang from 1996 to Avrag Paymnts for Dntal Srvis Inras from 1996 to Fs Charg for Dntal Srvis Vari btwn an within Communitis 22 Agny Commnts 30 Appnix I National Dntal Expniturs 32 Appnix II Urban an Rural Dntal Visit Rats 33 Appnix III Sop an Mthoology 34 Appnix IV Dntal Fs Charg for Common Dntal Prours in 18 Communitis 38 Appnix V GAO Contat an Staff Aknowlgmnts 74 Rlat GAO Prouts 75 Tabls Tabl 1: Catgoris an Exampls of Dntal Srvis 6 Tabl 2: Dsriptions of Dntal Covrag within Crtain Fral Halth Programs 8 Tabl 3: Prntag of Iniviuals with a Dntal Visit, 1996, 2004, an Tabl 4: Prntag of Iniviuals with a Dntal Visit, by Covrag Status, 1996, 2004, an Pag i

4 Tabl 5: Avrag Annual Dntal Paymnts for Iniviuals with a Dntal Visit, Ajust for Inflation, by Covrag Status, 1996, 2004, an Tabl 6: Prours with th Largst Prntag Diffrn btwn Mipoint an Uppr-En Fs, Tabl 7: Diffrns btwn Mipoint an Uppr-En Dntal Fs Charg for a Prioi Oral Evaluation of an Establish Patint, by Loal Dntists in 18 Communitis in Nin Stats, Tabl 8: Diffrns btwn Mipoint an Uppr-En Dntal Fs Charg for a Filling by Loal Dntists in 18 Communitis in Nin Stats, Tabl 9: Dntal Fs Charg for a Tooth Extration by Loal Dntists an Halth Cntrs in 18 Communitis in Nin Stats, Tabl 10: Dntal Fs Charg for Common Prours in Phonix, Arizona (850), Tabl 11: Dntal Fs Charg for Common Prours in Flagstaff, Arizona (860), Tabl 12: Dntal Fs Charg for Common Prours in Los Angls, California (900), Tabl 13: Dntal Fs Charg for Common Prours in Frsno, California (936), Tabl 14: Dntal Fs Charg for Common Prours in Miami, Floria (331), Tabl 15: Dntal Fs Charg for Common Prours in Palm Coast, Floria (321), Tabl 16: Dntal Fs Charg for Common Prours in Chiago, Illinois (606), Tabl 17: Dntal Fs Charg for Common Prours in Champaign, Illinois (618), Tabl 18: Dntal Fs Charg for Common Prours in Boston, Massahustts (021), Tabl 19: Dntal Fs Charg for Common Prours in Pittsfil, Massahustts (012), Tabl 20: Dntal Fs Charg for Common Prours in Minnapolis, Minnsota (554), Tabl 21: Dntal Fs Charg for Common Prours in Mankato, Minnsota (560), Tabl 22: Dntal Fs Charg for Common Prours in Nw York, Nw York (100), Pag ii

5 Tabl 23: Dntal Fs Charg for Common Prours in Elmira, Nw York (148), Tabl 24: Dntal Fs Charg for Common Prours in Nashvill, Tnnss (372), Tabl 25: Dntal Fs Charg for Common Prours in Jakson, Tnnss (382), Tabl 26: Dntal Fs Charg for Common Prours in Dallas, Txas (752), Tabl 27: Dntal Fs Charg for Common Prours in San Anglo, Txas (768), Figurs Figur 1: Dntal Covrag Status, 1996, 2004, an Figur 2: Rats of Privat Dntal Covrag, by Inom Lvl, 1996, 2004, an Figur 3: Dntal Covrag Rats for Chilrn, Ags 0-20 Yars, 1996, 2004, an Figur 4: Prntag of Chilrn, Ags 0-20 Yars, with Privat an Miai Dntal Covrag with a Dntal Visit, 1996, 2004, an Figur 5: Typs of Dntal Srvis as a Proportion of Total Srvis, 1996, 2004, an Figur 6: Avrag Annual Paymnts for Dntal Srvis for Iniviuals with a Dntal Visit, Ajust for Inflation, by Inom Lvl, 1996, 2004, an Figur 7: Avrag Annual Out-of-Pokt Paymnts for Iniviuals with a Dntal Visit, 1996, 2004, an Figur 8: Mipoint Dntal Fs in 18 Communitis for Tth Claning (Ault an Chil), Figur 9: National Expniturs for Dntal Srvis, Ajust for Inflation, Figur 10: Prntag of Iniviuals with a Dntal Visit, by Ag an Loation, Pag iii

6 Abbrviations ADA AHRQ CDT CHIP CMS CPI-U FPL HHS HRSA MEPS PPACA VA Amrian Dntal Assoiation Agny for Halthar Rsarh an Quality Currnt Dntal Trminology Stat Chilrn s Halth Insuran Program Cntrs for Miar & Miai Srvis Consumr Pri Inx for All Urban Consumrs fral povrty lvl Dpartmnt of Halth an Human Srvis Halth Rsours an Srvis Aministration Mial Expnitur Panl Survy Patint Prottion an Afforabl Car At Dpartmnt of Vtrans Affairs This is a work of th U.S. govrnmnt an is not subjt to opyright prottion in th Unit Stats. Th publish prout may b rprou an istribut in its ntirty without furthr prmission from GAO. Howvr, baus this work may ontain opyright imags or othr matrial, prmission from th opyright holr may b nssary if you wish to rprou this matrial sparatly. Pag iv

7 441 G St. N.W. Washington, DC Sptmbr 6, 2013 Th Honorabl Brnar Sanrs Chairman Subommitt on Primary Halth an Aging Committ on Halth, Euation, Labor, an Pnsions Unit Stats Snat Dar Mr. Chairman: Mor than a a ago, th Surgon Gnral s rport on oral halth srib th poor oral halth of our nation as a silnt pimi. 1 Toay, high rats of ntal isass rmain prvalnt aross th nation, spially in vulnrabl an unrsrv populations. Th ost of ntal ar an lak of ntal ovrag ar oftn it as rasons iniviuals may not sk n ntal ar. 2 In 2008, 42 prnt of aults with tooth or mouth problms rport thy i not s a ntist baus thy i not hav ntal ovrag or oul not affor th out-of-pokt paymnts. 3 Similarly, in 2011, 4 million hilrn i not obtain n ntal ar baus thir familis oul not affor it. 4 Th Institut of Miin has rport that thr is strong vin that ntal ovrag is positivly assoiat with ass to an us of oral halth ar. 5 1 U.S. Dpartmnt of Halth an Human Srvis, National Institut of Dntal an Craniofaial Rsarh, National Instituts of Halth, Oral Halth in Amria: A Rport of th Surgon Gnral (Rokvill, M.: 2000). 2 Iniviuals an obtain ntal ovrag from privat insuran or publi programs inluing Miai, Miar, Vtrans Affairs, or stat sponsor programs. 3 B. Bloom, C.M. Simil, P.F. Aams, an R.A. Cohn, Oral Halth Status an Ass to Oral Halth Car for U.S. Aults Ag 18 64: National Halth Intrviw Survy 2008, Vital an Halth Statistis 10(253) (Hyattsvill, M.: National Cntr for Halth Statistis, 2012). For our rport, insuran prmiums wr not inlu in out-of-pokt paymnts. 4 B. Bloom, R.A. Cohn, an G. Frman, Summary Halth Statistis for U.S. Chilrn: National Halth Intrviw Survy, 2011, Vital an Halth Statistis 10(254) (Hyattsvill, M.: National Cntr for Halth Statistis, 2012). 5 Institut of Miin an National Rsarh Counil, Improving Ass to Oral Halth Car for Vulnrabl an Unrsrv Populations. Th National Aamis Prss (Washington, D.C.: 2011). For xampl, on stuy foun that iniviuals who i not hav ntal insuran wr about two-thirs lss likly to hav a ntal visit than iniviuals with privat insuran. Pag 1

8 Rognizing that oral halth is ntral to a prson s ovrall halth an wll-bing, th Dpartmnt of Halth an Human Srvis (HHS) has aopt an oral halth objtiv as a laing halth iniator in its Halthy Popl 2020 initiativ, whih onsists of 10-yar national objtivs for improving th halth of all Amrians. 6 Spifially, HHS s laing iniator for oral halth is to inras th proportion of hilrn, aolsnts, an aults who us th oral halth ar systm in th past 12 months. Th 2020 targt for this laing halth iniator is to inras ass to ntal srvis inrasing th proportion of iniviuals ag 2 yars an olr who hav ha a ntal visit in a yar to 49.0 prnt from 44.5 prnt in Many familis that annot affor ntal ar obtain it from halth ntrs, for whih fral funs provi a substantial part of rvnu. Dntal srvis that ar provi by halth ntrs must b availabl to all patints, rgarlss of thir ability to pay. All halth ntrs must hav f shuls for all srvis, inluing any ntal srvis provi, that rflt prvailing fs in th ara an a shul of isounts (or sliing f shul) for iniviuals who arn annual inoms qual to or lss than 200 prnt of th fral povrty lvl (FPL). You ask us to xamin ntal ovrag, an us of an paymnts for ntal srvis in th Unit Stats. This rport sribs (1) trns in ovrag for an us of ntal srvis, (2) trns in paymnts for ntal srvis ma by iniviuals an othr payrs, an (3) th xtnt to whih ntal fs vary btwn an within slt ommunitis aross th nation. You also ask us to xamin national xpniturs for ntal srvis. W rport national ntal xpniturs from 1996 through 2011 in appnix I. To provi information on trns in ntal ovrag an th us of ntal srvis by typ of ovrag, w obtain an analyz ata fils from th Mial Expnitur Panl Survy (MEPS) for 1996, 2004, an 2010 on ntal visits, ntal srvis, an ovrag status. W slt ths 6 Halthy Popl 2020 is an HHS initiativ that provis sin-bas, 10-yar national objtivs for improving th halth of all Amrians. Halthy Popl stablishs bnhmarks an monitors progrss ovr tim in orr to nourag ollaborations aross ommunitis an stors, mpowr iniviuals towar making inform halth isions, an masur th impat of prvntion ativitis. S for mor information. Pag 2

9 yars for our analysis baus 1996 was th first yar MEPS was aministr an 2010 was th most rnt yar for whih ata wr availabl; w inlu 2004 to provi thr points in tim for our analysis. MEPS is aministr by HHS s Agny for Halthar Rsarh an Quality (AHRQ) an is a nationally rprsntativ survy of th noninstitutionaliz population, inluing familis, mial provirs, an mployrs aross th Unit Stats. W bas our analysis on a similar analysis onut by AHRQ for its Chartbook 17 publiation. 7 W analyz ata on ntal ovrag an ntal visits (inluing th atgory of srvi obtain uring th visit, suh as prvntiv or rstorativ) pr yar, as wll as iffrns in ovrag status an ntal visits bas on mographis suh as ag group an inom lvl. W also xamin us of ntal srvis by iniviuals in urban an rural aras; to nsur aquat sampl sizs, w ombin svral yars of MEPS ata. Information for th urban an rural analysis is prsnt in appnix II. MEPS ollts information on privat ntal ovrag but os not ollt information spifially about whthr ntal ovrag is inlu in halth plans offr by publi programs suh as halth ovrag provi by th Dpartmnt of Vtrans Affairs (VA), Dpartmnt of Dfns (DOD), or Miar Avantag. 8 Thrfor, w oul not trmin for this population whthr thos iniviuals ha ntal ovrag, an w atgoriz that group as unknown. To intify trns in ntal paymnts by iniviuals an othr payrs, that is, how muh iniviuals pai out of pokt for ntal ar an how muh ntal insurrs or othr payrs, suh as Miai, pai for ntal laims, w obtain an analyz MEPS 1996, 2004, an 2010 ata fils on 7 Chartbook 17 xamin MEPS ata rlat to ntal ovrag, us, an paymnts in 1996 an R.J. Manski an E. Brown, Dntal Us, Expnss, Privat Dntal Covrag, an Changs, 1996 an 2004, MEPS Chartbook No.17 (Rokvill, M.: Agny for Halthar Rsarh an Quality, 2007). S 8 Miar Part A ovrs hospital an othr inpatint stays. Miar Part B is optional insuran an ovrs hospital outpatint, physiian, an othr srvis. Miar bnfiiaris hav th option of obtaining ovrag for Miar Part A an B srvis from privat halth plans that partiipat in th Miar Avantag program also known as Miar Part C. Miar Avantag is a privat plan altrnativ to traitional Miar f-for-srvi an may provi bnfits, suh as ntal ovrag, not inlu in traitional Miar f-for-srvi. In 2010, about 25 prnt of Miar bnfiiaris wr nroll in Miar Avantag plans. Pag 3

10 ntal visits, paymnts, an ovrag status. 9 In aition, w analyz varians by mographi group, inluing ag group an inom lvl. To trmin th xtnt to whih ntal fs vari btwn an within rtain ommunitis, w analyz ntal laims ata ompil by FAIR 10 Halth, In. as of January 2013, an obtain ntal f shuls from slt frally fun halth ntrs. Th FAIR Halth ntal ata st ontains ovr 140 million laims, inluing gozip ata (th first 3 igits of a postal zip o 11 ) an Amrian Dntal Assoiation (ADA) Currnt Dntal Trminology (CDT) billing os. 12 W slt 24 ntal prours for omparison by intifying th CDT billing os with th most ntal laims in ah of six atgoris of ntal srvis fiv os ah for iagnosti, prvntiv, an rstorativ srvis; an thr ah for noonti, prioonti, an oral surgry srvis. Aami xprts an ADA offiials agr that our list of 24 CDT os was rprsntativ of th most ommon ntal prours. To slt larg ommunitis, w intifi th gozip with th most ntal laims in th or ity in th largst mtropolitan statistial ara in ah of th nin U.S. Cnsus Burau ivisions. 13 For omparison to our larg ommunitis, w slt nin small ommunitis in th sam stats bas on thir population. Baus gozip bounaris o not align with 9 For this rport, w rfr to MEPS ntal xpnss as ntal paymnts. 10 FAIR Halth, In., is an inpnnt, not-for-profit orporation that ompils ntal an mial laims ata (nonisount fs harg by provirs) from privat insurrs. S for mor information about FAIR Halth, In., an its ntal laims ata st. 11 FAIR Halth uss th trm gozip to rfr to an ara ovr by th first 3 igits of a postal zip o. Th U.S. Postal Srvi sribs a 3-igit zip o as th ara srv by a stional ntr faility, whih is a prossing an istribution ntr for all zip os bginning with thos 3 igits. Largr itis an inlu multipl 3-igit zip os. For xampl, th Los Angls/Long Bah mtropolitan ara inlus gozips 900 to 912 (xluing 909). 12 Cos on Dntal Prour an Nomnlatur ar th intlltual proprty of th ADA as opyright ownr. 13 Th U.S. Offi of Managmnt an Bugt linats mtropolitan statistial aras aoring to publish stanars that ar appli to Cnsus Burau ata. Th gnral onpt of a mtropolitan statistial ara is that of a or ara ontaining a substantial population nulus, togthr with ajant ommunitis having a high gr of onomi an soial intgration with that or. Th Cnsus Burau has nin ivisions: Nw Englan, Mil Atlanti, East North Cntral, Wst North Cntral, South Atlanti, East South Cntral, Wst South Cntral, Mountain, an Paifi. Pag 4

11 mtropolitan statistial ara signations, w slt on gozip (th on with th most ntal laims) to rprsnt ah larg an ah small mtropolitan ara. W xamin th 50 th prntil ntal f an th 95 th prntil ntal f for ah of our 24 CDT os from a gozip in ah larg an small ommunity. 14 To intify ntal fs harg by frally fun halth ntrs, w obtain oumntation an mt with offiials from HHS s Halth Rsours an Srvis Aministration (HRSA), whih aministrs th Halth Cntr Program. HRSA provi a list of halth ntrs that srv rsints of our 18 slt ommunitis an that provi ntal srvis. W obtain full f an sliing f shuls from on halth ntr that srv ah ommunity, although som halth ntrs i not provi or bill sparatly for all 24 prours. To trmin th rliability of th MEPS, FAIR Halth, an halth ntr ata, w rviw rlat oumntation, talk to agny offiials an aami xprts, an rviw othr stuis that us th ata to arss similar rsarh qustions. W trmin that th MEPS, FAIR Halth, an halth ntr ata wr suffiintly rliabl for th purposs of our rport. W onut this prforman auit from Otobr 2012 to Sptmbr 2013 in aoran with gnrally apt govrnmnt auiting stanars. Thos stanars rquir that w plan an prform th auit to obtain suffiint, appropriat vin to provi a rasonabl basis for our finings an onlusions bas on our auit objtivs. W bliv that th vin obtain provis a rasonabl basis for our finings an onlusions bas on our auit objtivs. (For mor information on our sop an mthoology, s app. III.) 14 Prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 95 prnt of rport fs fall blow th 95 th prntil. Pag 5

12 Bakgroun Dntal Srvis Dntal srvis ovr an array of prours, from prvntiv srvis, suh as lanings, to mor omplx srvis, suh as root anals (s tabl 1). Tabl 1: Catgoris an Exampls of Dntal Srvis Catgory Exampls Diagnosti X-ray Examination Prvntiv Claning Fluori appliation Salant appliation Rstorativ Fillings Crowns Enoonti Root anal Prioonti Tratmnt of th gums Oral Surgry Surgial rmoval of a tooth Sour: GAO summary of Amrian Dntal Assoiation (ADA) information. Dntal Covrag Most iniviuals with ntal ovrag hav privat ntal insuran. Privat ntal insuran plans may b a stan-alon plan or b inlu as a part of mial insuran. Stan-alon ntal plans rquir iniviuals to nroll sparatly; thy ar not a part of th iniviual s mial insuran plan. Th typs of ntal srvis ovr by ntal plans vary wily among privat plans. For xampl, on plan may inlu omprhnsiv ar suh as routin iagnosti an prvntiv srvis, rstorativ srvis, an oral surgry, whil anothr may ovr mor limit srvis suh as mrgny ar only. Cost sharing for ntal srvis usually involvs an annual utibl an aoring to a Burau of Labor Statistis survy of mployrs, in 2008, th mian utibl was $50 pr prson. 15 Aftr th iniviual mts th 15 Burau of Labor Statistis, Slt Mial Bnfits: A Rport from th Dpartmnt of Labor to th Dpartmnt of Halth an Human Srvis (Washington, D.C.: Apr. 15, 2011). This survy was onut by th Burau of Labor Statistis of mployrsponsor halth plans to trmin th bnfits typially ovr by mployrs. Pag 6

13 utibl, ntal plans may pay a prntag of ovr srvis up to a maximum annual bnfit. In 2008, th rport mian annual maximum was $1,500. Iniviuals may also obtain ntal ovrag in othr ways, suh as through fral programs. Fral programs may ovr ntal srvis as a rquir bnfit, support purhas of stan-alon ntal ovrag for ligibl bnfiiaris, or support ovrag of ntal srvis as part of broar ovrag unr iniviuals mial ovrag plans, for xampl. Bnfits inlu in ths typs of ovrag may vary wily pning on fators suh as typ of plan purhas, family inom, or vtran s status (s tabl 2). Pag 7

14 Tabl 2: Dsriptions of Dntal Covrag within Crtain Fral Halth Programs Program Miai a an Stat Chilrn s Halth Insuran Program (CHIP) Miar Dpartmnt of Vtrans Affairs (VA) Dpartmnt of Dfns TRICARE Dsription of ntal ovrag For hilrn in Miai, unr th Early an Prioi Srning, Diagnosti, an Tratmnt bnfit, stat Miai programs must provi ntal srvis, inluing iagnosti, prvntiv, an rlat tratmnt srvis, for all ligibl Miai bnfiiaris unr ag 21. For aults in Miai, ntal ovrag varis, as stats hav flxibility to trmin whthr to provi ntal bnfits for aults an if so, what srvis to inlu. For xampl, whil many stats ovr som ntal srvis for aults, suh as prvntiv xams, othr stats o not, limiting this bnfit to trauma ar or mrgny tratmnt for pain rlif an inftion. Stats may also rquir that rtain srvis hav prior approval, or pla limits on th total amount of srvis an nroll an riv ah yar. Whn CHIP was stablish in 1997, ovrag of ntal srvis was not a rquir bnfit. b Th Chilrn s Halth Insuran Program Rauthorization At of 2009 xpan fral rquirmnts for CHIP programs to ovr ntal srvis. Spifially, th at rquir stats to ovr ntal srvis in thir CHIP programs bginning in Otobr It also gav stats authority to us bnhmark plans to fin th bnfit pakag or to supplmnt hilrn s privat halth insuran with a ntal ovrag plan finan through CHIP. Stats that provi CHIP ovrag to hilrn through a Miai xpansion program ar rquir to provi th Early an Prioi Srning, Diagnosti, an Tratmnt bnfit. Stats with a sparat CHIP program may hoos from two options for proviing ntal ovrag: a pakag of ntal bnfits that mts th CHIP rquirmnts, or a bnhmark ntal bnfit pakag that is substantially qual to th (1) most popular fral mploy ntal plan for pnnts, (2) most popular plan slt for pnnts in th stat s mploy ntal plan, or (3) ntal ovrag offr through th most popular ommrial insurr in th stat. Gnrally, Miar os not ovr routin prvntiv or rstorativ ntal srvis. Miar f-for-srvi offrs ntal ovrag unr limit irumstans, for xampl, proviing ntal srvis that ar an intgral part of a ovr prour (.g., ronstrution of th jaw following aintal injury). Miar Avantag plans hav th flxibility to offr ovrag of routin prvntiv an rstorativ ntal srvis. Miar ntal ovrag varis by typ of Miar Avantag plan slt by bnfiiaris. VA ovrag of ntal srvis rquirs nrollmnt, an xat ovrag of ntal srvis varis by an iniviual vtran s status for xampl, whthr th vtran has a srvi-onnt isability. In som instans, VA may provi omprhnsiv ntal ar, whil in othr ass ovr ntal srvis may b limit. For xampl, som vtrans with srvi-onnt isabilitis ar ligibl for any nssary ntal ar. Othr vtrans ar only ligibl for ntal ar if thir ntal problms may ompliat xisting mial onitions. TRICARE th Dpartmnt of Dfns s rgionally strutur halth ar systm offrs ntal bnfits as a sparat program that for many bnfiiaris rquirs sparat nrollmnt. Th TRICARE Dntal Program an TRICARE Rtir Dntal Program ar voluntary an rquir nrollmnt. Th TRICARE Ativ Duty Dntal Program supplmnts srvis provi at military ntal tratmnt failitis for ativ uty srvi mmbrs. Bnfits vary by program an ligibility for xampl, familis may hav to purhas a supplmntal ntal poliy outsi of thir mial ovrag to obtain ntal ovrag. Sour: GAO summary of agny information. a Miai, a joint fral an stat program that provis halth ar ovrag for rtain low-inom iniviuals an familis, provi halth ovrag for an stimat 70 million nrolls in fisal yar Pag 8

15 2011. Stats oprat thir Miai programs within broa fral rquirmnts an may ontrat with manag ar organizations to provi Miai mial an ntal bnfits. b Stats an aministr thir CHIP programs as (1) an xpansion of thir Miai program, (2) a stan-alon program, or (3) a ombination of Miai xpansion an stan-alon. Pub. L. No , 501, 123 Stat. 8, 84. Miar Part A ovrs hospital an othr inpatint stays. Miar Part B is optional insuran an ovrs hospital outpatint, physiian, an othr srvis. Miar bnfiiaris hav th option of obtaining ovrag for Miar Part A an B srvis from privat halth plans that partiipat in th Miar Avantag program also known as Miar Part C. In 2010, about 25 prnt of Miar bnfiiaris wr nroll in Miar Avantag plans. Miar Avantag is a privat plan altrnativ to traitional Miar f-for-srvi an may provi bnfits, suh as ntal ovrag, not inlu in traitional Miar f-for-srvi. Dntal Car Provi by Halth Cntrs HHS s HRSA rport that in 2011, ovr 4 million patints us ntal srvis at frally fun halth ntrs. 16 Unr th Halth Cntr Program, halth ntrs whih must b loat in frally signat mially unrsrv aras or srv a frally signat mially unrsrv population ar rquir to provi piatri ntal srnings an prvntiv ntal srvis, as wll as mrgny mial rfrrals, whih may also rsult in th provision of ntal srvis. Halth ntrs may provi rquir srvis, inluing rquir ntal srvis, irtly or via formal ontrat or rfrral agrmnts. Howvr, halth ntrs ar not rquir to provi a full rang of ntal srvis. A halth ntr must stablish a f shul for its srvis that is onsistnt with loally prvailing rats an rflts th halth ntr s rasonabl osts of proviing srvis. A halth ntr must also stablish a sliing f shul for iniviuals who arn annual inoms 17 qual to or lss than 200 prnt of th FPL. HRSA rport that in 2011, ovr 92 prnt of th mor than 20 million patints srv by halth ntrs nationwi ha inom lss than or qual to 200 prnt of th FPL (an wr ligibl for a sliing sal f bas on inom an family siz) U.S.C. 254b. Halth ntrs ar fun in part through grants unr th Halth Cntr Program aministr by HRSA an provi omprhnsiv primary ar srvis for th mially unrsrv. 17 Th 2013 fral povrty guilins stat that a family of four at 200 prnt of th povrty lvl has an inom of $47,100 pr yar. 18 Aoring to HRSA offiials, ata spifi to ntal patints wr not availabl. Pag 9

16 Dntal Car unr th Patint Prottion an Afforabl Car At Th Patint Prottion an Afforabl Car At (PPACA) has signat piatri ntal ar as an ssntial halth bnfit that nw halth plans must ovr in th nw halth ar xhangs an th small-group an iniviual markts. Exhangs may allow plans to offr stan-alon ntal ovrag proviing, at a minimum, piatri ntal ar. Ault ntal ovrag is not inlu as an ssntial halth bnfit. Plans that hav granfathr status unr th law ar not rquir to offr piatri ntal ovrag. 19 PPACA has th potntial to hang th bnfits an out-of-pokt paymnts assoiat with ntal ovrag; howvr, th xtnt of ths hangs is unrtain. National Survy Data Show That Rats of Dntal Covrag an Us of Dntal Srvis Rmain Gnrally Unhang from 1996 to 2010 Covrag of Dntal Srvis Rmain Rlativly Unhang from 1996 to 2010 Th rat of iniviuals with ntal ovrag rmain largly unhang from 1996 to 2010; aroun 62 to 63 prnt of th population ha privat or Miai or CHIP ntal ovrag. In aition, from 1996 to 2010, th prntag of iniviuals who ha a ntal visit rmain about th sam, aroun 41 to 43 prnt. Our analysis of MEPS ata show that ovrall, th rat of ntal ovrag th prntag of iniviuals rporting that thy ha ntal ovrag through privat insuran or Miai or CHIP rmain rlativly unhang from 1996 to Spifially, in 1996, 62 prnt of iniviuals rport having ntal ovrag, an in 2010, 63 prnt rport having ntal ovrag. For about 10 to 12 prnt 19 Privat halth ar plans in xistn as of Marh 23, 2010, ar onsir granfathr plans that o not hav to omply with rtain PPACA ovrag rquirmnts. Howvr, plans may los thir granfathr status if thy ut bnfits or inras bnfiiary ost sharing. 20 For purposs of this rport, w rfr to hilrn in Miai an CHIP as hilrn in Miai, baus th MEPS ata o not istinguish btwn hilrn in Miai an CHIP. Pag 10

17 of th population, inluing many iniviuals ovr by Miar an othr fral halth programs, ntal ovrag status is unknown. 21 Whil th ovrall prntag of iniviuals with ntal ovrag gnrally stay th sam btwn 1996 an 2010, th prntags with privat ntal an without insuran ovrag ras an th prntag with Miai ntal ovrag inras. Spifially, th prntag of iniviuals with privat ovrag was 53 prnt in 1996 an 50 prnt in 2010 (s fig. 1). Th prntag of iniviuals with ntal ovrag unr Miai inras staily in ah of th yars w xamin, from 9 prnt in 1996 to 13 prnt in Th prntag of iniviuals rporting that thy i not hav ntal ovrag ras from 28 prnt in 1996 to 25 prnt in 2010, laving at last on in four iniviuals with no ntal ovrag approximatly 76 million popl in For 10 to 12 prnt of iniviuals in ah yar w xamin, it is unknown whthr thy ha ntal ovrag. Ths iniviuals rport having som typ of halth ovrag, suh as Miar ovrag, but th MEPS survy strutur i not allow us to trmin whthr that halth ovrag inlu ntal ovrag. 21 Most of ths iniviuals rport having Miar ovrag. Traitional Miar offrs vry limit ntal bnfits. Miar Avantag plans may inlu ntal ovrag. In 2010, about 25 prnt of Miar bnfiiaris wr in a Miar Avantag plan, but not all plans offr ntal ovrag or offr ntal ovrag as an optional bnfit. Consquntly, this onsrvativ approah may rsult in ovrstating th unknown atgory an unrstating th non atgory. Pag 11

18 Figur 1: Dntal Covrag Status, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. Iniviuals in th unknown atgory iniat that thy ha othr typs of publi ovrag, inluing stat or fral programs suh as Miar or vtran s bnfits. Ths programs might not hav inlu ntal ovrag, or might hav provi limit ntal ovrag to rtain iniviuals. For ths programs, th MEPS survy mthoology i not allow us to intify whih bnfiiaris atually ha ntal ovrag. Bnfiiaris in ths programs with a ntal laim pai by privat insuran uring th prio wr ount as having privat ovrag. For xampl, Miar Avantag nrolls who ha a laim pai by privat insuran wr ount in th privat insuran atgory. Miar bnfiiaris who i not hav a laim pai by privat insuran wr inlu in th unknown atgory baus thy might hav ha ntal ovrag, suh as unr a Miar Avantag plan, but i not us thir ovrag uring th survy prio. Rats of privat ntal ovrag among iniviuals in th high-inom atgory (ovr 400 prnt of FPL) wr highr than any othr inom atgory in 1996, 2004 an 2010 (s fig. 2). Iniviuals in th poor-, low-, an mil-inom groups saw a lin in th rats of privat ovrag ovr th sam prio For this analysis, poor iniviuals ar iniviuals in familis with inom at or blow 100 prnt of th FPL. Th low-inom group is iniviuals in familis with inom at or blow 200 prnt of th FPL but abov 100 prnt of th FPL. Iniviuals in th mil-inom group ar thos in familis with inom at or blow 400 prnt of th FPL, but abov 200 prnt of th FPL. Pag 12

19 Figur 2: Rats of Privat Dntal Covrag, by Inom Lvl, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population. Inom is xprss in trms of povrty status. For this analysis, poor rfrs to iniviuals in familis with inom at or blow 100 prnt of th fral povrty lvl (FPL). Th low-inom group is iniviuals in familis with inom at or blow 200 prnt of th FPL but abov 100 prnt of th FPL. Th mil-inom group is iniviuals in familis with inom at or blow 400 prnt of th FPL but abov 200 prnt of th FPL. Th high-inom group is iniviuals in familis with inom gratr than 400 prnt of th FPL. Th prntag of iniviuals with Miai ntal ovrag inras from 9 prnt in 1996 to 13 prnt in This trn was largly rivn by an inras in hilrn ovr by Miai, whih rquirs piatri ntal ovrag. Th ovrall prntag of hilrn (ags 0-20 yars) rport to hav ntal ovrag through privat ovrag or Miai inras from 72 prnt (59 million) in 1996 to 81 prnt (71 million) in 2010, an fwr hilrn wr uninsur, baus mor hilrn wr ovr by Miai in 2010 than in prior yars. Th prntag of hilrn with ntal ovrag through Miai inras from 18 prnt (15 million) in 1996 to 33 prnt (29 million) in 2010 (s fig. 3). This was th largst inras in ovrag for any ag group in Miai. Th prntag of hilrn with privat ntal Pag 13

20 ovrag ras from 54 prnt (44 million) in 1996 to 48 prnt (42 million) in In aition, rats of hilrn without ntal ovrag lin from 27 prnt (22 million) to 17 prnt (15 million) ovr th sam prio. Figur 3: Dntal Covrag Rats for Chilrn, Ags 0-20 Yars, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population. Th unknown atgory for this ag group is not rport in this figur baus of small sampl sizs (fwr than 2 prnt of hilrn ags 0-20 yars wr rport as having unknown ntal ovrag). For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. Us of Dntal Srvis Rmain Rlativly Unhang from 1996 to 2010 Th prntag of iniviuals who us ntal srvis thos who rport having at last on ntal visit uring th yar rmain rlativly unhang at aroun 40 prnt from 1996 to Spifially, about 43 prnt of iniviuals in 1996 an 41 prnt in 2010 ha a ntal visit. Tabl 3 shows our analysis of MEPS ata on th us of ntal srvis. Pag 14

21 Tabl 3: Prntag of Iniviuals with a Dntal Visit, 1996, 2004, an Dntal visit No ntal visit Total Sour: GAO analysis of HHS ata. Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This tabl inlus only th noninstitutionaliz population. Trns in ntal visits by iniviuals with privat ntal ovrag largly xplain why th prntag of iniviuals with a ntal visit rmain rlativly unhang from 1996 to Spifially, ovr this prio th prntag of iniviuals with privat ntal ovrag who ha a ntal visit rmain th sam, at aroun 56 prnt (s tabl 4), an iniviuals with privat ovrag ma up a larg majority aroun 80 to 85 prnt of th population with ntal ovrag uring that tim prio. Th numbr of iniviuals without ntal ovrag who ha a ntal visit lin from 26 prnt, or 19 million iniviuals, in 1996 to 18 prnt, or 14 million iniviuals, in Tabl 4: Prntag of Iniviuals with a Dntal Visit, by Covrag Status, 1996, 2004, an Privat Miai a Unknown Non Sour: GAO analysis of HHS ata. Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This tabl inlus only th noninstitutionaliz population with a ntal visit. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. a Iniviuals in th unknown atgory iniat that thy ha othr typs of publi mial ovrag, inluing stat or fral programs suh as Miar or vtran s bnfits. Ths programs might not hav inlu ntal ovrag, or might hav provi limit ntal ovrag to rtain iniviuals. For ths programs, th MEPS survy mthoology i not allow us to intify whih bnfiiaris atually ha ntal ovrag. Bnfiiaris in ths programs with a ntal laim pai by insuran uring th prio wr ount as having privat ovrag. For xampl, Miar Avantag nrolls who ha a laim pai by privat insuran wr ount in th privat insuran atgory. Miar bnfiiaris who i not hav a laim pai by insuran wr inlu in th unknown atgory baus thy might hav ha ntal ovrag suh as unr a Miar Avantag plan, but i not us thir ovrag uring th survy prio. Pag 15

22 Th prntag of iniviuals with Miai who ha a ntal visit inras from 1996 to This inras rflts an inras in th numbr of hilrn with Miai ovrag who ha a ntal visit, although ths hilrn still ha ntal visits at lowr rats than privatly insur hilrn (58 prnt). Th prntag of hilrn with Miai ntal ovrag with a ntal visit inras from 28 prnt, or 4 million hilrn, in 1996 to 37 prnt, or 11 million hilrn, in (S fig. 4.) Figur 4: Prntag of Chilrn, Ags 0-20 Yars, with Privat an Miai Dntal Covrag with a Dntal Visit, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus th noninstitutionaliz population with a ntal visit. From 1996 to 2010, 72 prnt to 81 prnt of hilrn ags 0-20 yars ha privat or Miai ntal ovrag. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. Among iniviuals who rport having a ntal visit, thr was an inras in th prntag rporting that thy riv iagnosti an prvntiv srvis (for xampl, xams an lanings) an a ras in thos rporting that thy riv othr srvis, suh as rstorativ srvis (for xampl, fillings), from 1996 to Spifially, th prntag of visits for iagnosti an prvntiv srvis as a proportion Pag 16

23 of total ntal srvis inras (s fig. 5). Svnty-six prnt of ntal visits in 2010 onsist of iagnosti or prvntiv srvis (43 an 33 prnt, rsptivly). This is an inras from 69 prnt in 1996, whn iagnosti an prvntiv srvis ma up 40 an 29 prnt of srvis riv, rsptivly. Th prntag of visits for othr typs of srvis ras from 1996 to Spifially, rstorativ srvis suh as fillings ras slightly from 8 prnt to 6 prnt as a proportion of total ntal srvis riv in thos yars. Othr srvis that ras inlu prosthti an orthoonti srvis. Figur 5: Typs of Dntal Srvis as a Proportion of Total Srvis, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population an prsnts th prntag of visits that wr for ah atgory of ntal prour. Th othr atgory inlus tratmnt for tmporomanibular joint an musl isorrs (jaw pain), boning, whitning or blahing, as wll as prioonti, prosthti, orthoonti, oral surgry, an noonti srvis. Pag 17

24 Avrag Paymnts for Dntal Srvis Inras from 1996 to 2010 Avrag annual paymnts ma on bhalf of or by iniviuals for ntal srvis inluing paymnts from othr payrs suh as insurrs an out-of-pokt paymnts inras from 1996 to Avrag annual inflation-ajust ntal paymnts inras 26 prnt from $520 pr yar in 1996 to $653 pr yar in 2010 (s tabl 5). Th avrag annual paymnts ma inluing out-of-pokt paymnts an paymnts by othr payrs inras 24 prnt for th privatly insur, 39 prnt for iniviuals with Miai, an 38 prnt for thos without ntal ovrag. In aition, in 2010, avrag annual ntal paymnts (out of pokt an paymnts ma by othr payrs) for thos with privat ovrag wr narly twi as muh as th paymnts ma by an on bhalf of iniviuals with Miai ovrag. Tabl 5: Avrag Annual Dntal Paymnts for Iniviuals with a Dntal Visit, Ajust for Inflation, by Covrag Status, 1996, 2004, an Avrag paymnt $520 $647 $653 Privat Miai a Unknown Non Sour: GAO analysis of HHS ata. Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This tabl inlus only th noninstitutionaliz population with a ntal visit. In MEPS, paymnts ar fin as th sum of paymnts for ar riv, inluing out-of-pokt paymnts an paymnts ma by privat insuran, Miai, Miar, an othr payrs. Paymnts wr ajust for inflation using th Consumr Pri Inx for All Urban Consumrs (CPI-U), 2010 ollars. Dashs iniat th sampl siz was too small for a rliabl stimat. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. a Iniviuals in th unknown atgory iniat that thy ha othr typs of publi mial ovrag, inluing stat or fral programs suh as Miar or vtran s bnfits. Ths programs might not hav inlu ntal ovrag, or might hav provi limit ntal ovrag to rtain iniviuals. For ths programs, th MEPS survy mthoology i not allow us to intify whih bnfiiaris atually ha ntal ovrag. Bnfiiaris in ths programs with a ntal laim pai by insuran uring th prio wr ount as having privat ovrag. For xampl, Miar Avantag nrolls who ha a laim pai by privat insuran wr ount in th privat insuran atgory. Miar bnfiiaris who i not hav a laim pai by insuran wr inlu in th unknown atgory baus thy might hav ha ntal ovrag suh as unr a Miar Avantag plan, but i not us thir ovrag uring th survy prio. 23 In MEPS, paymnts ar fin as th sum of paymnts for ar riv, inluing out-of-pokt paymnts an paymnts ma by privat insuran, Miai, an othr payrs. Thy o not inlu prmium osts. Paymnts wr ajust for inflation using th Consumr Pri Inx for All Urban Consumrs (CPI-U), 2010 ollars. Pag 18

25 Avrag annual paymnts for ntal srvis vari aross inom lvls. Paymnts ma by an on bhalf of iniviuals in th low-, an mil-inom groups inras staily from 1996 to Howvr, avrag annual paymnts ma by an on bhalf of iniviuals who wr poor inras from $373 in 1996 to $493 in 2004, an thn ras to $437 in For low-inom iniviuals, that is, iniviuals with inoms at or blow 200 prnt but abov 100 prnt of th FPL, ntal paymnts ha th largst inras. Spifially, avrag annual ntal paymnts for th low-inom group inras from $393 in 1996 to $558 in 2010 (s fig. 6), about 42 prnt. Avrag annual ntal paymnts also inras for mil- an high-inom iniviuals 23 an 25 prnt, rsptivly. 24 Poor inlus iniviuals in familis with inom at or blow 100 prnt of th FPL. Pag 19

26 Figur 6: Avrag Annual Paymnts for Dntal Srvis for Iniviuals with a Dntal Visit, Ajust for Inflation, by Inom Lvl, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population with a ntal visit. In MEPS, paymnts ar fin as th sum of paymnts for ar riv, inluing out-of-pokt paymnts an paymnts ma by privat insuran, Miai, Miar, an othr sours. Paymnts wr ajust for inflation using th Consumr Pri Inx for All Urban Consumrs (CPI-U), 2010 ollars. For this analysis, poor ar iniviuals in familis with inom at or blow 100 prnt of th fral povrty lvl (FPL). Th low inom group is iniviuals in familis with inoms at or blow 200 prnt of th FPL but abov 100 prnt of th FPL. Th mil-inom group is iniviuals in familis with inom at or blow 400 prnt of th FPL but abov 200 prnt of th FPL. Th highinom group is iniviuals in familis with inom gratr than 400 prnt of th FPL. Iniviuals out-of-pokt paymnts for ntal srvis, sparat from paymnts by othr payrs, whn ajust for inflation, gnrally inras from 1996 to 2010 (s fig. 7). Spifially, avrag annual out-of-pokt paymnts ma by iniviuals with privat ovrag inras 21 prnt from 1996 to 2010 from $242 to $294. Iniviuals with no ntal ovrag xprin th gratst inras in avrag annual out-of-pokt paymnts, from $392 to $518, a 32 prnt inras. For iniviuals with Miai ovrag, thir avrag annual Pag 20

27 out-of-pokt paymnts rmain rlativly unhang, $64 in 1996 an $59 in Figur 7: Avrag Annual Out-of-Pokt Paymnts for Iniviuals with a Dntal Visit, 1996, 2004, an 2010 Nots: Data ar from Mial Expnitur Panl Survy (MEPS). This tabl inlus only th noninstitutionaliz population with a ntal visit. Paymnts wr ajust for inflation using th Consumr Pri Inx for All Urban Consumrs (CPI-U), 2010 ollars. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. Th out-of-pokt paymnts for iniviuals in th unknown group ar not rport in th figur baus of sampl siz onrns an high rlativ stanar rrors in th stimat. Rlativ stanar rror is th proportion of th stanar rror ivi by th stimat itslf. 25 Cost sharing in Miai for most srvis is limit to nominal amounts. S Sharing/Cost-Sharing.html (ass May 24, 2013). Pag 21

28 Fs Charg for Dntal Srvis Vari btwn an within Communitis Dntal fs harg by ntists an halth ntrs vari aross gographi aras an within ommunitis. For 24 ommon ntal prours, ntal fs harg by loal ntists vari signifiantly btwn th 18 ommunitis w xamin. In aition, ntal fs vari wily within ommunitis. Dntal fs also vari btwn loal ntists an halth ntrs that srv rsints of th sam ommunity, but all halth ntrs ar rquir to offr sliing f shuls for low-inom iniviuals. Dntal Fs Vari Wily btwn Communitis For 24 ommon ntal prours, mipoint ntal fs th amount whr half of fs harg wr highr an half wr lowr vari wily btwn th 18 ommunitis w xamin. 26 For xampl, mipoint ntal fs for an ault prophylaxis (ommonly all tth laning) in larg ommunitis rang from $76 in Nashvill, Tnnss, to $155 in Nw York, Nw York. In smallr ommunitis, mipoint fs rang from $59 in Jakson, Tnnss, to $88 in Frsno, California (s fig. 8). Similarly, mipoint fs harg for a hil prophylaxis rang from $55 to $105 in larg ommunitis an $48 to $71 in small ommunitis. Dntal fs, as with othr halth ar osts, vary by loation. (S tabls 10 to 27 in app. IV for mor information on th rang of ntal fs for othr ommon ntal prours in slt ommunitis.) 26 W analyz ntal insuran laims ata in nin stats orrsponing to th nin U.S. Cnsus ivisions. Using 2010 Cnsus ata, w slt two ommunitis in ah stat, on larg, bas on thir population an volum of ntal laims an on small bas on population. Our nin slt ommunity pairs, larg an small (with slt gozip), wr Phonix (850) an Flagstaff (860), Arizona; Los Angls (900) an Frsno (936), California; Miami (331) an Palm Coast (321), Floria; Chiago (606) an Champaign (618), Illinois; Boston (021) an Pittsfil (012), Massahustts; Minnapolis (554) an Mankato (560), Minnsota; Nw York (100) an Elmira (148), Nw York; Nashvill (372) an Jakson (382), Tnnss; an Dallas (752) an San Anglo (768), Txas. (S app. III for mor information on our sop an mthoology.) Pag 22

29 Figur 8: Mipoint Dntal Fs in 18 Communitis for Tth Claning (Ault an Chil), 2012 Not: Fs ar rport for Currnt Dntal Trminology (CDT) os D1110: Prophylaxis (Ault) an D1120: Prophylaxis (Chil). Th Amrian Dntal Assoiation sribs prophylaxis (ommonly all tth laning) as rmoval of plaqu, alulus, an stains from th tooth struturs in th prmannt an transitional ntition. Svral fators an ontribut to gographi variation in ntal fs, inluing loal wags an th ost of spa an quipmnt n to oprat a prati. Although w intifi no urrnt pr-rviw rsarh that stablish a orrlation btwn iniviual fators an th lvl of ntal fs, gographi variation in spning for mial srvis Pag 23

30 is wll oumnt. For xampl, th Congrssional Bugt Offi rport that a numbr of fators, inluing failitis, supplis, an wags, influn gographi variation in halth ar spning. 27 Th Cntrs for Miar & Miai Srvis (CMS), in stting Miar paymnt rats for halth ar srvis, stablishs a gographi prati ost inx for ah Miar paymnt loality to aount for variation in prati xpnss. CMS rport that it i not hav any omparabl prati ost inx for Miai ntal fs. Dntal Fs Vari Wily within Communitis Dntal laims ata also show signifiant iffrns within ommunitis for all 24 ommon ntal prours w xamin. Fs within th privat prati ntal stting ar afft by loal markt onitions an isions within th iniviually own pratis. FAIR Halth ntal laims ata show that within ommunitis th iffrn btwn mipoint an uppr-n fs was as high as 143 prnt for loaliz livry of antimirobial agnts. Uppr-n fs wr at last oubl th mipoint fs in at last on ommunity for 8 of th 24 ommon prours w xamin (s tabl 6). (S app. IV for information on all 24 prours in all 18 slt ommunitis.) 27 Congrssional Bugt Offi, Gographi Variation in Halth Car Spning, Pub. No (Washington, D.C.: Fb. 2008). Pag 24

31 Tabl 6: Prours with th Largst Prntag Diffrn btwn Mipoint an Uppr-En Fs, 2012 Currnt Dntal Trminology (CDT) o Dsription Community (gozip) Mipoint f Uppr-n f Prntag iffrn D4381 Loaliz Dlivry of Antimirobial Los Angls, Calif. (900) $80 $ % Agnts via a Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D0120 Prioi Oral Evaluation Establish Miami, Fla. (331) Patint D0230 Raiographs/Diagnosti Imaging: Nw York, N.Y. (100) Intraoral Priapial Eah Aitional Film D1203 Topial Appliation of Fluori Chil Los Angls, Calif (900) D0274 Raiographs/Diagnosti Imaging: Miami, Fla. (331) Bitwings Four Films D7140 Extration, Erupt Tooth or Expos Nw York, N.Y. (100) Root (Elvation an/or Forps Rmoval) D0220 Raiographs/Diagnosti Imaging: Miami, Fla. (331) Intraoral Priapial First Film D1204 Topial Appliation of Fluori Ault Los Angls, Calif. (900) Sour: GAO analysis of FAIR Halth ata (as of January 2013). Amrian Dntal Assoiation (ADA) CDT finitions. Not: Mipoint fs ar th 50 th prntil an uppr-n fs ar th 95 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 95 prnt of rport fs fall blow th 95 th prntil). Dntal fs within ommunitis also vari wily for iagnosti prours. For th most ommon iagnosti prour, a prioi oral valuation of an stablish patint, th prntag iffrn btwn rport mipoint an uppr-n fs in larg ommunitis rang from 20 prnt to 142 prnt (s tabl 7). For xampl, in Miami, Floria, half of th fs harg by ntists for a prioi oral xamination of an stablish patint wr $62 or lss, but 5 prnt of fs harg for that prour wr $150 or mor, a 142 prnt iffrn. In small ommunitis, th prntag iffrn was lss, ranging from 17 prnt to 58 prnt. Pag 25

32 Tabl 7: Diffrns btwn Mipoint an Uppr-En Dntal Fs Charg for a Prioi Oral Evaluation of an Establish Patint, by Loal Dntists in 18 Communitis in Nin Stats, 2012 Community (gozip) Mipoint f Uppr-n f Prntag iffrn Larg ommunitis Miami, Fla. (331) $62 $ % Nw York, N.Y. (100) Los Angls, Calif. (900) Chiago, Ill. (606) Phonix, Ariz. (850) Nashvill, Tnn. (372) Boston, Mass. (021) Dallas, Tx. (752) Minnapolis, Minn. (554) Small ommunitis San Anglo, Tx. (768) $38 $60 58 Frsno, Calif. (936) Jakson, Tnn. (382) Palm Coast, Fla. (321) Pittsfil, Mass. (012) Elmira, N.Y. (148) Champaign, Ill. (618) Mankato, Minn. (560) Flagstaff, Ariz. (860) Sour: GAO analysis of FAIR Halth ata (as of January 2013). Amrian Dntal Assoiation (ADA) Currnt Dntal Trminology (CDT) finitions. Nots: Fs ar rport for CDT o D0120: Prioi Oral Evaluation (Establish Patint). ADA sribs this prour as an valuation prform on a patint of ror to trmin any hangs in th patint s ntal an mial halth status sin a prvious omprhnsiv or prioi valuation. This inlus an oral anr valuation an prioontal srning whr iniat, an may rquir intrprtation of information aquir through aitional iagnosti prours. Mipoint fs ar th 50 th prntil an uppr-n fs ar th 95 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 95 prnt of rport fs fall blow th 95 th prntil). Dntal fs within ommunitis also vari wily for rstorativ prours. For th most ommon rstorativ prour, a filling, th prntag iffrn btwn rport mipoint an uppr-n fs in larg ommunitis rang from 19 prnt to 67 prnt (s tabl 8). For xampl, in Phonix, Arizona, half of th fs harg by ntists for a filling wr $195 or lss, but 5 prnt of fs harg for that prour wr $325 or mor, a 67 prnt iffrn. In small Pag 26