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It’s Complicated: Dental Coverage Under the Affordable Care Act Institute for Oral Health Conference September 12, 2013 Colin Reusch, Senior Policy Analyst Children ’ s Dental Health Project. Children’s Dental Health Project. Mission: Creating and advancing innovative

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Presentation Transcript

It’s Complicated:

Dental Coverage Under the

Affordable Care Act

Institute for Oral Health Conference

September 12, 2013

Colin Reusch, Senior Policy Analyst

Children’s Dental Health Project


Children’s Dental Health Project

  • Mission: Creating and advancing innovative
  • solutions to achieve oral health for all children.
  • Our Approach
  • Reduce dental disease burden
  • Improve access to high-quality dental care
  • Our Goals
  • Preventchildhood tooth decay, because cavities are the result of a disease that is overwhelmingly preventable.
  • Promote solutions that are grounded in the best available research and support exploration when evidence is lacking
  • Engage policymakers and other decision-makers in addressing ongoing inequities in oral health and to implement cost-effective solutions.
oral health and the aca
Oral Health and the ACA

Integrated, comprehensive plan to improve the nation’s oral health 

23 provisions focusing on:






coverage what congress intended
Coverage: what Congress intended
  • Expand dental coverage to nearly all children
  • Make dental coverage an integral part of kids’ coverage
  • Improve quality and affordability of dental care
  • Make prevention-focused, science-based practice a priority
  • Bridge the gaps between medical and dental care & providers
  • Systematically bolster & improve the entire oral health care system

How Children Get Dental

Coverage Under the ACA

Source: Colin Reusch and Joe Touschner. Pediatric Dental Benefits Under the ACA: Issues for State Advocates to Consider


Essential Health Benefits:

Pediatric Dental Coverage

background pediatric dental benefit
Background: Pediatric Dental Benefit

EHB Category 10: “Pediatric services, including oral and vision care”

State-selected benchmarks

Part of a comprehensive pediatric benefit

Stand-alone dental plans may provide Exchange coverage

If a stand-alone participates, Qualified Health Plans (QHPs) exempt from oral care requirement

Statute treats pediatric dental benefits differently depending on issuer

essential health benefit ehb selection process
Essential Health Benefit (EHB) Selection Process

States selected benchmark plans (services covered)

If pediatric dental is missing from a state’s EHB benchmark, the state must choose either:

The Federal Employees Dental and Vision Insurance Program (FEDVIP) dental plan with the largest national enrollment; or

The State’s separate CHIP program

For pediatric dental: 31 states use FEDVIP, 19 use CHIP, 1 uses state employee plan

aca potential enrollment impact
ACA Potential Enrollment Impact

Source: Milliman, Inc. analysis commissioned by the ADA; Analysis by the ADA Health Policy Resources Center.

major reforms to dental coverage
Major Reforms to Dental Coverage

Major Reforms:

No annual and lifetime dollar limits

Out-of-pocket (OOP) maximums

Federally-facilitated marketplaces (FFMs): $700/$1,400

State marketplaces can define

Availability of child-only plans

Availability of premium tax credits (up to 400% FPL)

Network adequacy requirement

Quality reporting requirement

complicating factors
Complicating Factors

No requirement to purchase separate dental inside exchanges

Outside exchange – QHPs must have “reasonable assurance” of purchase

Cost-sharing reductions don’t apply to stand-alone dental

Regulations allow for separate but additional “reasonable” OOP max for stand-alone dental

Does not vary according to income

1 year exemption on OOP max for small group plans health plans with multiple benefit administrators

premium tax credits
Premium Tax Credits

Tax credits available for families up to 400% FPL

Applicable to pediatric dental coverage

Tax credit goes to insurers on behalf of enrollees

Goes to QHP first, residuals go to stand-alone dental plans

IRS Tax Credit Rule: tax credit amount may be insufficient to cover cost of separate dental

premium tax credits continued
Premium Tax Credits, Continued

How is the tax credit calculated?

Tax credit is calculated based on the second-lowest cost silver plan in the Marketplace which may or may not include pediatric dental benefits.

If second-lowest cost silver plan does not include pediatric dental, tax credit will not be sufficient to cover the cost of this coverage.

Families purchasing silver-level health coverage and stand-alone pediatric dental coverage may receive a tax credit only large enough to cover the cost of health coverage.

consumer protections
Consumer Protections

The ACA includes numerous market reforms for all benefits provided through a QHP.

The ACA removes annual and lifetime dollar limits on health and dental coverage.

Protections that apply to QHPs but not stand-alone dental plans:

Protection against denials for pre-existing conditions

Guaranteed issue/renewal

Fair insurance premiums (based only on age and geography)

Guaranteed premium rates

Right to external appeals process

consequences of current regulatory approach
Consequences of Current Regulatory Approach


Comprehensive benchmark plans

Some standardization between state-based and FFMs

OOP Max issues pose potential affordability barriers

Tax credit issue could prevent many from purchasing

Questions about enrollment and outreach

approaching the starting line
Approaching the Starting Line

October 1 – enrollment begins

January 1 – marketplace coverage begins

Between now and then, marketplaces will be scrambling

Training navigators & assisters

Ensuring IT systems are stable

Advertising & conducting outreach

helping families choose coverage
Helping families choose coverage

Factors to consider

Covered services

Plan cost-sharing structures

Out-of-pocket (OOP) maximums

Cost-sharing reductions

Deductibles (especially in embedded plans)

Premium rates

Availability of tax credits

Consumer protections

monitoring implementation
Monitoring & Implementation

Engaging in your state

Join oral health & ACA coalitions

Identify decision-makers

Find “feedback loops”

Collect stories & data

Join outreach & education efforts

monitoring implementation1
Monitoring & Implementation
  • What questions should we ask?
    • What is the consumer/family experience like?
    • Who’s purchasing coverage and why or why not?
    • What barriers are families encountering?
      • Affordability, lack of knowledge, too many choices?
    • Are provider networks sufficient?
    • Are children getting treatment?
    • How is integration of dental into health plans changing the coverage landscape?
    • What needs to change in order to achieve the triple aim?
issues on the horizon
Issues on the Horizon
  • Dental coverage in Medicaid expansion for adults (ongoing)
  • Fixing dental affordability issues in ACA (ongoing)
    • Tax credits, OOP limit issues, etc.
  • Fixing dental coverage gaps in ACA (ongoing)
  • CHIP Funding/reauthorization (2015)
  • Review of Essential Health Benefits (2016)
  • ACA Quality measurement/reporting requirements (2016)

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…or contact us!

Colin Reusch, MPA