ACA dental benefits: the way forward

By the CDHP team

This guest blog post is written by Andy Snyder, who is program manager at the National Academy for State Health Policy, where he is responsible for analyzing state policies related to eligibility, enrollment, and benefit design in Medicaid and CHIP programs.

As readers of CDHP's "Teeth Matter" blog know, the Affordable Care Act (ACA) includes pediatric dental services as one of 10 essential health benefits that health plans in the small group and individual markets must cover. However, the way that the ACA structures dental coverage has created a number of implementation challenges to ensuring dental coverage for children, particularly in regard to financial supports that help individuals purchase insurance. In our recent report, the National Academy for State Health Policy (NASHP) describes these issues in detail and offers policy options to improve how health insurance marketplaces deliver dental coverage in future years.

Federal regulations don’t extend many affordability protections to dental coverage. Stand-alone dental products are not included in the calculation of tax credits that help individuals under 400 percent of the Federal Poverty Level purchase marketplace coverage.

Federal regulations don’t extend many affordability protections to dental coverage.

Stand-alone dental products may also have a separate out-of-pocket maximum stacked on top of the out-of-pocket spending limit for a medical plan.  And some medical plans that include children’s dental coverage don’t have a separate deductible for medical services — meaning that families might need to pay a significant amount out-of-pocket before their insurance would begin to cover pediatric dental costs. (A recent ADA study found that, among a sample of “embedded” plans, 34 percent had a single deductible averaging $2,935.)

In January 2014, NASHP brought together a group of 20 officials from state insurance marketplaces, national experts, and dental stakeholder groups (including CDHP) to identify actions that state and federal policymakers could consider to improve how dental benefits are provided.

Options range from enacting legislation or regulation (like California’s 2013 state law to cap all out-of-pocket spending at a single level) to operational changes in plan solicitation and website design (like Kentucky’s marketplace website, which requires applicants who have a child in their household to purchase dental coverage before “checking out”).  Experts also made recommendations for monitoring strategies to track and improve the provision of dental benefits.

State and federal officials have already begun work to prepare for the 2015 ACA open enrollment season, and dental coverage is one of many thorny issues that they are grappling with.  Our hope is that this report will provide state and federal officials, as well as oral health stakeholders, with ideas for ways to evaluate dental offerings and improve consumer experience in obtaining dental coverage.

(Note: The opinions expressed by guest bloggers or interview subjects do not necessarily reflect the opinions of CDHP.)

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Did you know?

44% }
of U.S. children will have at least one cavity by kindergarten.
More on the state of dental health ›