One of the key oral health elements of the Affordable Care Act (ACA) is the inclusion of pediatric dental as an essential health benefit (EHB). Recognizing the importance of having this benefit, HealthReformGPS recently posted a brief about how exchanges will offer pediatric dental benefits. We applaud the attention to this important benefit, and would like to add a few statements to further clarify the issue.
The HealthReformGPS brief points out there are two ways pediatric benefits will be offered: through a comprehensive plan that offers both medical and dental or through a stand-alone dental plan.
Under ACA, if an exchange offers stand-alone dental plans, qualified health plans on that exchange are not required to offer pediatric dental benefits. There is the assumption among many people that when a stand-alone dental plan is offered, the exchanges will “package” the medical and pediatric dental plans together, so the purchaser ends up with both. While this may be an option on some state-based exchanges, it is not the case universally.
In fact, according to guidance from the United States Department of Health and Human Services (HHS),
a) the pediatric dental benefit is not required to be purchased by those shopping on an exchange, even by those with eligible children, and
b) the Federally-Facilitated Marketplaces operated by HHS will not be able to support the offer of bundled medical and pediatric dental plans, at least in the first year.
The unfortunate consequence is that people may purchase a qualified health plan on an exchange and not get the important pediatric dental benefit coverage. This runs counter to intent of the ACA and its goal of ensuring all children have access to pediatric dental benefits.
Outside the Marketplaces
Ironically, when a health plan is purchased outside of an exchange, the ACA requires that the pediatric dental benefit be included. The only way that a health plan can opt not to include the pediatric dental benefits is if the purchaser has already purchased the pediatric dental benefits from an exchange-certified stand-alone dental plan. The unfortunate consequence of the law as it is currently written is that low-income, childless adults will also be required to purchase a pediatric dental benefit that they cannot use. While we agree that families with eligible children should be enrolled in pediatric dental benefits, we hope the law is amended to exclude childless adults from this requirement.
The HealthReformGPS brief also discussed the credits available to low-income families to purchase insurance through the exchanges. The credit available to families will be calculated based on the premium associated with all 10 EHBs, including dental. When dental is purchased separately, the amount of the credit will be allocated first to the Qualified Health Plan and then to the dental plan.
Essential is Essential
We believe the most important piece on which to focus the discussion is ensuring that all children have pediatric dental coverage whether their plan is purchased on or off the exchanges. That is the intent of the ACA. Tooth decay is the most common chronic illness among school-age children. It affects one in every four children, yet it is almost entirely preventable when children have access to care and preventive education. The rate of tooth decay among low-income children is more than twice that for children with more income (31 percent versus 14 percent), according to the Kaiser Family Foundation.
Clearly, it is imperative that all children have access to dental benefits. The ACA is a major step in making this happen by including pediatric dental and vision as an essential health benefit. That’s not exactly how the rules are working today. With our colleagues in the dental community, we are working with federal policymakers to ensure that all children have this benefit.