Although mandatory pediatric dental insurance was included in U.S. healthcare reform, actual coverage is a stark departure from the benefits envisioned by the Patient Protection and Affordable Care Act (ACA) and those required under Medicaid, according to a new report. Coverage isn't always as comprehensive as it should be and is often unaffordable for families, the authors concluded.
The policy brief was released on September 14 by the Georgetown University Health Policy Institute Center for Children and Families. It starts with good news: In the six years since the Children's Health Insurance Program (CHIP) and the ACA were passed, the number of children without dental coverage has been cut by more than half. However, coverage varies greatly regarding comprehensiveness and affordability, according to the authors.
"As implemented, the benefits on paper are a stark departure from the benefits envisioned by the ACA and, certainly, from those required under Medicaid," wrote Colin Reusch, a senior policy analyst at the Children's Dental Health Project (CDHP), and Joan Alker, executive director of the Georgetown's Center for Children and Families.
Oral healthcare requirements
The ACA requires private health insurers to cover certain oral healthcare services with no out-of-pocket costs for children and families. These services include the following:
- Fluoride varnish application for all children through the age of 5 by a physician
- Fluoride supplements for children living in areas without community water fluoridation
- Oral health risk assessment by a physician and referral to a dentist
But these basic services are inadequate to meet the most pressing needs of children, many of whom are in dire need of restorative care, the authors noted. Also, high deductibles in many insurance policies make needed dental care unaffordable for families.
The ACA allows a variety of pediatric dental offerings in the marketplaces, but the outcomes of these offerings have been far more complicated, according to Reusch and Alker:
- Standalone dental plans don't provide consumer protections established by the ACA, such as guaranteed rates and rights to an external appeals process.
- Cost-sharing reductions for low-income families don't apply to standalone dental plans.
- The Internal Revenue Service has ruled the cost of standalone pediatric dental coverage cannot be included in premium tax credits.
"Altogether, these factors erect a considerable barrier to affordability for families purchasing dental coverage through standalone plans in the marketplace," they wrote.
Since ACA benchmarks don't list what dental services must be covered, many insurance plans aren't tailored to the actual needs of children. For example, children at higher risk for caries may need more frequent dental visits and more help -- such as counseling or fluoride treatments -- to keep the disease from progressing, the authors noted. At the other end of the spectrum, lower-risk children may only need to visit a dentist a couple of times a year.
The states can choose which services must be covered in the insurance marketplaces. Utah, for example, picked plans that only cover cleanings and x-rays but not restorative or orthodontic care, according to the report.
In some areas, families who want to buy dental coverage for their children must get it through a standalone dental plan. This entails additional cost-sharing burdens, including paying an average of nearly $30 per child, per month in additional premiums -- with no additional tax credit to help cover the costs, the authors pointed out.
They cited California, Connecticut, Maryland, and the District of Columbia as good examples of how to provide children's dental coverage in the marketplace. These states have established standard plan designs that shield pediatric dental services from high medical deductibles while incorporating them into qualified health plans.
"The federal government could ensure that families shopping on the federally facilitated marketplaces receive more comprehensive and affordable dental coverage for their children through a similar approach," the authors noted.
Reusch and Alker listed six recommendations to improve the program:
- Establish standard plans for qualified health plans in federal and state marketplaces that include comprehensive pediatric dental coverage without high deductibles.
- Include pediatric dental coverage in the tax credit calculation.
- Expand benefits to include comprehensive oral health services, ensuring that caries is treated like other chronic conditions.
- Adopt the dental coverage standard of the Children's Health Insurance Program.
- Encourage state Medicaid programs to align policies and care delivery with established clinical guidelines and allow the states to refine their Medicaid programs to strengthen oral health among preschool-age children.
- Develop measures that evaluate whether children are getting risk-based oral health assessments.
"Policymakers at the state and federal levels have options available to them that could vastly improve the delivery of children's oral health care," the authors concluded.