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By Ian Wasser

Is there really a clear distinction between dental health issues and “traditional” health issues?

The American Dental Association reports that evidence suggests that gum disease and periodontal disease both have negative consequences on heart health.  Heart disease is the leading cause of death in the United States.  Wouldn’t it make sense to consider all of the potential factors that contribute to heart disease, including high cholesterol, high triglycerides, high blood pressure, gum disease, and periodontal disease in the same category?  And, along this same line of reasoning, shouldn’t dental coverage be included in all general health insurance policies?

Typically, employers that offer group health insurance plans also offer separate group dental insurance plans.  While the availability, renewability, and portability of  health insurance plans are all subject to HIPAA regulation, additional “add-on” insurance coverage like dental and vision plans are excluded from HIPAA regulation.  42 U.S.C. § 300gg-21.  This has the effect of denying an employee, who elects add-on insurance coverage, a certificate of creditable coverage should his or her employer change add-on insurance plans.

What this could mean is that, with each successive change in dental insurance plans, an employee is potentially barred from coverage for pre-existing dental issues.  But, dental health deteriorates with age–isn’t every cavity necessarily a pre-existing condition? By failing to include dental benefits as an “integral part of the plan,” employers fail to encourage their employees to seek dental insurance and to see a dentist regularly.  In the long-term, this jeopardizes both the health of the employee and adds costs for the employer–certainly heart disease is more expensive to treat when compared to paying for routine dental check-ups.

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2 Comments

  1. Not seeing an exclusion of dental care from the definition of healthcare providers, or from the definition of healthcare.

    Those of us who are HIPAA Privacy Officers have, without exception to my knowledge, always included dental health providers as being included under the HIPAA umbrella.

    Unable to find the citation you provided. Can you copy/paste it to me? Does 42 USC specifically state that “dental care” is excluded as an “add on insurance coverage excluded from HIPAA”?

    45 CFR § 160.103 Definitions.

    Health care means care, services, or supplies related to the health of an individual. Health care includes, but is not limited to, the following:
    (1) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and
    (2) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.

    Health care provider means a provider of services (as defined in section 1861(u) of the Act, 42 U.S.C. 1395x(u)), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.

  2. Thank you for your comments. I think the mix-up stems from my post focusing on limitations for pre-existing conditions under HIPAA, while your comments seem related to privacy issues under HIPAA.

    Under 42 USC section 300gg(c)(1)(J), the term “creditable coverage” does not include “coverage consisting solely of coverage of excepted benefits (as defined in section 300gg-91(c) of this title.”

    42 USC section 300gg-91(c)(2)(A) is entitled “Benefits not subject to requirements if offered separately.” The benefits not subject to requirements include (A) limited scope dental or vision benefits; (B) benefits for long-term care; and (C) other similar limited benefits.

    While a dentist is arguably a health care provider, dental benefits might not be considered a part of a group health plan. This is likely the case when the dental benefits package is included as a supplemental package and requires an optional buy-in by the beneficiary. If, however, the dental insurance was included in the group health plan and without optional buy-in, then the dental coverage would most likely be covered under the “pre-existing condition limitations” conferred under HIPAA.

    To be clear, the portions of HIPAA that I discuss relate to exclusions for pre-existing conditions and not privacy of health information. I would agree that HIPAA privacy requirements likely extend to dentists and dental records, although I have not thoroughly considered that issue.


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