The ACA Pediatric Dental Benefit: Issues for Consumer Assisters and Oral

Health Stakeholders to Consider

Colin ReuschSenior Policy Analyst

Children’s Dental Health Project

The materials and opinions presented are that of the speaker and do  not represent the opinions and/or position of the U.S. Department of Health and Human Services and that of the Health Resources and Services Administration.

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OVERVIEW: ORAL HEALTH & DENTAL BENEFITS

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Overview: Oral Health

• Oral health is essential to overall health and impacts:– Nutrition– Learning– Social development– Employment– Military readiness

• More than half of new military recruits are unfit for deployment as a result of dental disease.

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Overview: Oral Health

• Tooth decay is 5 times more prevalent than asthma, affecting:– More than one-fourth of children 3-5 years;– and half of adolescents

• Takes hold early in life• Can be prevented and managed with

early intervention and:– Fluoride, good nutrition, and healthy habits

• About 1 in 7 kids and adolescents lack dental coverage (MEPS).

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Overview: Dental Benefits• Not traditionally a true insurance product

– Most often has an annual dollar limit on coverage (avg. = $1,200)• Most often separate from medical insurance or “stand-alone”• Cost-sharing (amount patient pays out-of-pocket) varies by category of

services, example of typical dental benefits structure:

Dental Services Member Pays Plan Pays

Preventive & Diagnostic (cleanings, x-rays, fluoride treatments, sealants)

0% 100%

Minor Restorative (fillings, simple extractions) 20% 80%

Major Restorative (root canals, crowns, gum surgery, implants, dentures, wisdom tooth extraction)

50% 50%

Orthodontics (braces, etc.) 50% 50%

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DENTAL BENEFITS UNDER THE ACA: ESSENTIAL HEALTH BENEFITS (EHB)

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EHB: Dental Benefits

• ACA reforms to pediatric dental benefits:– Makes it part of essential health benefits (EHB)

• Offered in Marketplaces (exchanges) and small group/individual insurance markets in each state

– Attempts to subsidize through premium tax credits– Limits cost-sharing (out-of-pocket maximums)– Removes annual and lifetime dollar limits on coverage

(children only)– Requires offering of child-only plans (up to age 19)– Limits orthodontic coverage to medically necessary

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EHHB: Dental Benefits

How is dental coverage available

in the new marketplaces?• For Children:

– Stand-alone dental plan or embedded in qualified health plan (QHP)

– Insurers must offer child-only plans– Stand-alone: “High” and “Low” options may be available:

• Actuarial Value (AV) of 85% and 70% respectively• For Adults:

– Adult dental coverage may be available but is not part of the EHB• No tax credit available• Traditional dental insurance with dollar limits

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EHB: Dental Benefits

How can dental benefits be offered in the marketplaces?

Pediatric EssentialHealth Benefits

Qualified Health Plan (QHP)

Stand-Alone Dental

QHP Including Dental

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EHB: Dental Benefits

Stand-alone• Optional to purchase (unless

state requires)• Separate deductible• Separate out-of-pocket

maximum• No cost-sharing reductions• Some consumer protections

may not apply• Not included in tax credit

calculation

QHP w/ Embedded Dental• Integrated dental benefits for

all enrolled children• One premium for health and

dental• May have high unified

deductible• Plan documents often lack

adequate dental information

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2014 DENTAL PLAN EXAMPLES

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Example: SD Delta Dental Silver Pediatric Stand-Alone Dental Plan

100%: Type I - Diagnostic & Preventive 50%: Type II - Routine Restorations

• Routine examinations - two per coverage year.• Routine dental cleaning (prophylaxis) - two per coverage year.• Bitewing x-rays - two per coverage year.• Full mouth/panoramic x-rays - one in any five-year interval.• Fluoride applications - two per coverage year.• Space maintainers (fixed, band type) on primary posterior teeth up to age 14.• Dental sealants - once for unrestored 1st and 2nd permanent molars of children up

to age 16.

• Silver (amalgam) fillings, and tooth-colored (composite) fillings. If a tooth colored filling is used to restore back (posterior) teeth, benefits are limited to the amount paid for a silver filling.

50%: Type III - Extractions, Root Canals, Periodontal Disease, Crowns, Bridges, Dentures, and Implants

50%: Orthodontics

• Crown buildups/posts. • Pre-formed or stainless steel restorations. Root canals. • Relines, repairs and recementations.• Treatment of diseases of the tissues supporting the teeth.• Crowns when teeth cannot be restored with another filling material.• Extractions and other oral surgery.• Emergency treatment for relief of pain.• Bridges, partial dentures, complete dentures, and implants.

• Medically necessary treatment for the proper alignment of teeth. See handbook for definition of “Medically Necessary Orthodontic Treatment”.

Deductible: $50 per child per coverage year. The deductible does not apply to orthodontic services.OOP Max: $700 per child, $1400 per two or more children ($350 & $700 for 2015)

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Example: WY BestOne Pediatric Stand-Alone Dental Plan

In-Network Out-of-Network

Diagnostic & Preventive Services

Plan covers 100% Plan covers 60%

Basic Services Plan covers 55% Plan covers 40%

Major Services Plan covers 35% Plan covers 20%

Medically Necessary Orthodontics

Plan covers 50% Plan covers 50%

Deductible: $50 per child per coverage year. Applies to preventive out of network, basic and major services in or out of network.OOP Max: $700 per child, $1400 per two or more children ($350 & $700 for 2015)

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WY WINhealth (QHP with embedded dental)

Service Bronze or Silver

Gold or Platinum

Limits & Exceptions

Preventive Dental Services

100% 100% Exams and/or Prophylaxis once every six months; Fluoride treatment once every twelve months; Sealants on posterior permanent teeth once every three years.

Basic Dental Services 60% 80% Bitewing x-rays once every six months; Full Mouth X-rays limited to once every five years; Synthetic restorations (white fillings) on posterior (back) teeth are optional and are payable as an amalgam (silver filling) benefit.

Major Dental Services 50% 50% Pre-authorization is required on oral surgery and it must also meet the Delta Dental of Wyoming definition of medical necessity. Preauthorization is required on all crowns, bridges, dentures and implants.

Orthodontics 50% 50% Preauthorization is required and must meet the Delta Dental of Wyoming definition of medical necessity. A two year waiting period is required on all orthodontics.

Deductible: ranges from $4,000 for bronze plans to $750 for platinum plans. Deductible applies to all but preventive services.

OOP Max: ranges from $6,350 for bronze plans to $1,500 for platinum plans. Applies to all medical and dental services.

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Example: UT BestOne Stand-Alone Pediatric Dental Plan

100%: Diagnostic & Preventive Services

• Routine oral exam• Cleanings• Fluoride treatment• X-rays• Sealants

50%: Orthodontic Services (30% out of network)

• Diagnosis and treatment for repair of cleft palate, severe craniofacial defects or injury impacting function of speech, swallowing or chewing.

Deductible: $75 per child per coverage year. Applies to preventive out of network & all basic and major services. OOP Max: $700 per child, $1400 per two or more children ($350 & $700 for 2015)

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What is ideal dental coverage?

Pediatric dental coverage should:• Cover the full range of dental services a child or

adolescent needs, including medically-necessary orthodontics.

• Pose little or no barrier to accessing basic preventive services.

• Be affordable.• Have adequate provider networks.• Avoid undue delay of care.

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Connecticut Pediatric Dental Options: Embedded

Dental Services Member Pays (Bronze)

Member Pays (Silver)

Member Pays (Gold)

Member Pays (Platinum)

Preventive & Diagnostic

0% 0% 0% 0%

Basic Restorative 40% 40% 20% 40%

Major Restorative 50% 50% 40% 50%

Orthodontic (medically Necessary)

50% 50% 50% 50%

Family Deductible $6,350* $6,000 $2,000 $0

*Deductible applies to all but Preventive & Diagnostic Services (Bronze only)

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QUESTIONS?

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Questions?

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PLAN STRUCTURE AND CONSUMER ASSISTANCE

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Choosing Dental Coverage

• Factors to consider– Covered services– Plan cost-sharing structure– Out-of-pocket (OOP) maximums– Cost-sharing reductions– Deductibles– Premium rates– Availability of tax credits– Consumer protections

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Covered Services, Cost-sharing, & Deductibles

• State-selected EHB defines what services must be covered.

• Cost-sharing (how much the plan pays for specific services) may vary from plan to plan

• Some plans may have different deductibles

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Covered Services, Cost-sharing, & Deductibles

Example Only

Stand-Alone Dental Plan

QHP with Embedded Dental

Service Category Plan Pays Plan Pays

Preventive & Diagnostic 90% 100%*

Basic Restorative 55% 80%*

Major Restorative 35%* 60%*

Orthodontics 50%* 50%*

Deductible $50 $2,000*Deductible must be met before plan covers services

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Covered Services, Cost-sharing, & Deductibles

Take-aways:• Plans in a state cover the same services• Cost-sharing & deductibles varies by plan• Consumers should understand how much

they are expected to pay for services• High deductibles can be a barrier to care

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• Reduction in OOP limits for QHPs vary by income

• Stand-alone dental plans have a separate OOP maximum:– In addition to medical OOP maximum– Does not vary by income– $350 per child/$700 multiple children (Plan Year 2015)

• If dental benefits are part of QHP, medical OOP maximum applies to all benefits

Out-of-Pocket (OOP) Maximums

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Out-of-Pocket Maximums

Take-aways:• Stand-alone dental plans have a separate OOP

maximum in addition to OOP maximum for QHPs

• Stand-alone dental OOP maximum does not vary according to income

• Consumers should understand whether meeting the QHP OOP maximum for dental is an affordability barrier for them

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Premium Tax Credits

Dental Benefits and Premium Tax Credits• The ACA subsidizes the purchase of EHB coverage

through premium tax credits • Available to individuals & families with incomes between

100- 400% FPL• Tax credits are paid to insurers on behalf of enrollees.• Tax credit goes first to health plan (QHP); any remaining

tax credit is then paid to stand-alone dental plan.

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Premium Tax Credits

How is the tax credit calculated?• Based on the second-lowest cost silver health plan in the

marketplace• If this plan does not cover pediatric dental, the tax credit

will be based only on the cost of health services• The cost of stand-alone pediatric dental coverage is not

included in this calculation• Families purchasing silver-level health coverage and

stand-alone pediatric dental coverage will likely not have any tax credit available to support the purchase of dental coverage.

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Premium Tax Credits

Example: Montana family of 4 w/ annual income of $70,650• Annual premium obligation = $6,712 (9.5% of income) • 2nd lowest cost silver plan (no dental) = $7,694• Tax credit: $7,694 – 6,712 = $982

• Dental premium (2 kids) = $528• Total premium obligation = $7,240 (10.3% of income)

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Premium Tax Credits

Take-aways:• Tax credits are based on the cost a benchmark

health plan in each market.• If no QHPs in the marketplace include pediatric

dental, the tax credit amount is based only on the cost health coverage.

• Consumers should understand that there may not be enough tax credit to cover the cost of stand-alone dental coverage.

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OTHER AREAS OF INTEREST AND CONCERN

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Consumer Protections

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

• The ACA removes annual and lifetime dollar limits on coverage for stand-alone dental plans.

• The following do not apply to benefits provided through a stand-alone dental plan:– Protection against denials for pre-existing conditions– Guaranteed issue/renewal– Fair insurance premiums (based only on age and geography)– Right to external appeals process

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Network Adequacy

• The ACA requires that all plans in the marketplace have an adequate provider network but standards for dental plans are vague.

• Consumers should review available plan information to make sure preferred providers in their area are included in the network:– Prospective patients may need to call dentists offices in their

area to find one in their network– The insurance plans should also be able to provide a list of

providers

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Network Adequacy

• Consumers may also look to Essential Community Providers (ECPs) such as:– Federally qualified health centers (FQHCs)– Ryan White providers– Family planning providers– Indian providers– Specified hospitals (Disproportionate Share Hospitals, Children’s

Hospitals, Rural Referral Centers, Sole Community Hospitals, Critical Access Hospitals)

• “ECPs include providers described in section 340B of the PHS Act and section 1927(c)(1)(D)(i)(IV) of the Social Security Act.”

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Network Adequacy

Take-aways:• Plans must have adequate networks but

measurement of adequacy is not clear for dental• Essential Community Providers (ECPs) must be

included in plan networks in FFMs.• Consumers should understand what types of

providers are available to them in when purchasing dental coverage

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RECAP: WHAT CONSUMERS NEED TO KNOW

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Recap: What Consumers Need to Know

• How pediatric dental benefits will be available to them• How dental benefits work and how plans differ (services,

plan structure, cost-sharing, deductibles)• The financial impact of their choice of dental benefits

(OOP maximums, cost-sharing reductions, premium rate differences, tax credit amount and applicability)

• Consumer protections available to them• What providers are available to them

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YOUR ROLE: DEMYSTIFICATION AND SURVEILLANCE

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Your Role

• Navigators/Assisters: Serving as a resource to consumers, helping to demystify dental coverage

• State Oral Health Programs: Serving as a resource to state stakeholders, applying your dental expertise

• Health and Dental Plans: Marketing, public education, additional plan information, further consumer assistance training, tracking enrollment

• State Dental & Primary Care Associations: Helping providers understand the ACA’s dental coverage landscape, noting network adequacy issues, helping consumers understand payment

• State Oral Health Coalitions: Coordinating & Collaborating to identify issues and bring together key stakeholders on improving implementation

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Your Role

What questions should we ask?• Are consumers purchasing coverage?• How can providers, insurers, & other stakeholders collaborate

to maximize enrollment?• What is the consumer/family experience like?• What barriers are consumers encountering?• Are provider networks sufficient?• Are ECPs included in dental plan networks?• Are children getting treatment?• What needs to change in order to achieve better oral health

outcomes (state-based marketplaces have more flexibility in decision-making)?

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Questions?

Colin Reusch, MPA creusch@cdhp.org

202.417.3595http://www.cdhp.org