The rule also require standalone dental plans to offer child-only plans in the insurance exchanges.
The final rule governing how states should set up insurance exchanges and qualified health plans (QHP) cover how Americans can buy essential health benefits, including mandated pediatric dental coverage.
The requirements clarify that families will have the same level of consumer protections, affordability standards, and access to pediatric dental coverage whether they purchase that coverage from a standalone dental plan or a QHP.
"While we wish that everyone in the family will be eligible for subsidized dental coverage, the way the law stands now only children are eligible," Colin Reusch, policy analyst for the Children's Dental Health Project (CDHP), told DrBicuspid.com. "So we want to make sure that families have the option that if they can't afford full family dental coverage, they can purchase the pediatric coverage that will be subsidized."
Other requirements of the rule include:
- Insurance exchanges must ensure that participating dental plans have the provider network capacity to offer sufficient access to all eligible children.
- Standalone dental plans must comply with all certification standards for QHPs except for those related to services other than pediatric oral healthcare.
- Insurance exchanges must collect rate information on pediatric dental benefits to determine advance payments of the premium tax credit.
"These provisions stand to greatly improve dental coverage in terms of access, affordability and quality for families in the exchanges, regardless of how they get their coverage," according to a CDHP statement.
What will be covered
The rules still leave some discretion to the states in how standalone dental plans should be treated and offered on the exchanges, noted Chris Pyle, director of state government and public relations for the Delta Dental Plans Association.
"Congress acknowledged that dental benefits operate differently from medical benefits, and they also recognized the value of preserving the way the market currently operates," Pyle told DrBicuspid.com. "Since the vast majority of people today get their dental benefits separately from their medical benefits, the ACA allows individuals to purchase the pediatric dental benefits from standalone dental benefits plans. We are glad that HHS affirmed this language in the ACA and clarified that this is not an option."
“If they include orthodontics with no maximum, it will become a question of how affordable it's going to be.”
— William Kohn, DDS, Delta Dental Plans
Exactly what will be covered under the mandated pediatric dental benefits requirements remains unclear, but Reusch noted that the rules refer to a benchmark approach that would probably include procedures normally covered under most employer and government plans.
"The problem is that current plans don't provide child-only coverage, so the task will be figuring out how to translate that into true pediatric coverage that really addresses the needs of a child," he said.
Since annual and lifetime limits will not be allowed under essential pediatric dental benefits, Pyle said standalone benefit plans like Delta will be watching to see what procedures will be included.
"Depending on if and how an orthodontia benefit is defined, that could have real implications on affordability," he said. "Annual and lifetime limits have always been used to keep benefits affordable."
William Kohn, DDS, vice president of dental science and policy with the Delta Dental Plans Association and former director of the Division of Oral Health at the U.S. Centers for Disease Control and Prevention, said orthodontic procedures typically cost $4,000 to $5,000, but dental plans usually impose lifetime limits between $500 to $1,500.
"If they include orthodontics with no maximum, then it will become a question of how affordable it's going to be," he told DrBicuspid.com. "The question becomes who will buy it, and how much subsidy will be provided by the government?"
Tax credits will be available only for coverage included in the 10 categories of essential health benefits under adult medical benefit coverage and for pediatric dental care.
The CDHP and Delta Dental both support a risk-based, individualized approach to mandated pediatric coverage.
"Our concern is ensuring that families have affordable coverage that's comprehensive, and we're really hoping states will opt for a risk-based approach to pediatric coverage that would assess each child for risk factors and determine a treatment plan that's individualized, which isn't what we see in the market today," Reusch explained. "It's one way of saving costs on care that is potentially unnecessary and really focusing on the services that each child needs."
Delta's Pyle concurred: "Delta Dental has recommended an approach to defining the essential pediatric dental benefit that is based on risk factors versus a one-size-fits-all approach."