You've heard that the Tricare dental plan for active duty families and Guard and Reservists and their families is changing May 1 from MetLife to United Concordia, and that coverage for users is getting better. But you may have also heard Tricare dentists complaining about the new system -- and that they are planning to leave the network, which could result in more out of pocket costs to you, the user.
So what's going on? I've spent a lot of time researching this, talking to dentists, United Concordia and Tricare and reading the Tricare dental contract documents so you don't have to. Here's what's going on -- and what it means to you. You can also read my entire news story on Military.com.
Fewer Tricare dentists? What you need to know:
Coverage is going up, but payments to dentists are going down. Yes, you're getting slightly better benefits and slightly lower premiums. Although I haven't reviewed every region's pay charts -- United Concordia says they are proprietary and refuses to release them -- I have been given them by dentists in a few different regions. According to those documents the amount United Concordia is paying dentists for their services is going down by a lot. For example, if you're in the San Antonio area and you need a white filling (many dentists don't even do silver fillings any longer) on two to three surfaces of a tooth, your dentist will be reimbursed about $28 to about $33 less than he or she was under MetLife. The average reimbursement rate in that region for about 50 common procedures is dropping by almost $34.
Dentists say they can't afford to be in the United Concordia Tricare network. The dentists I spoke with for my story said that accepting the fees the insurance company is willing to pay them means that, in some categories of service, they can't break even.
So what does this mean for using Tricare dentists?
You may have fewer local in-network dental options. The Tricare dental contract requires United Concordia to provide in-network general dentists within 35 driving miles of 95 percent of dental plan enrollees, and appointments with 21 days of requesting one. Thirty-fives miles is a major haul for a dentist appointment -- about an hour round trip if all you're doing is hitting a normal freeway. And the standard only applies to general dentists, not specialists like pediatric dentists. Tricare says there is a standard for access to specialists, but they wouldn't tell me what it is.
You can still go out of network, but it's going to cost more. A quirk in the MetLife contract that dentists told me was very, very unusual ("I've never seen anything like it," one longtime dentist told me) paid dentists more for being out of network than in network. The trade-off, however, was that Tricare also, in turn, charged you more and you reached your annual spending cap faster. After MetLife paid their max amount to the dentist, you paid the remainder.
The new contract, however, removes that oddity. Instead, both in and out-of-network dentists will be paid the same, lower, amount. So who has to pick up the bill for the remainder of what the out of network is charging? You. That means in addition to paying your cost share (example: fillings carry a 20 percent cost share), you'll be paying whatever the remaining balance is after United Concordia does its thing.
If enough dentists drop the plan, United Concordia will likely have to raise their rates. Because of the access benchmark in the contract, if enough dentists stay out of the network, United Concordia will have to temporarily pay dentists what they are actually charging until they get enough in the network to meet the standard. Getting dentists into the network who previously declined will likely require raising the rates they are offering. But this process could take more than a year.
The best way to learn your dentist's plans is to call the office. It's hard to tell who is in network -- and who is out. Because Tricare dentists don't need to notify United Concordia until March 31 whether or not they plan to be in network, the United Concordia dentist finder currently shows that many dentists are in network who have no plans to be. All of the dentists I spoke with plan to stay out of network. Only one of them is not currently displayed on the United Concordia site as being in network.
