By Leigha Basini, National Academy for State Health Policy
The new year brings many new things: new discussions about CCIIO’s newly released Essential Health Benefits (EHB) Bulletin and benefit provisions in the seemingly still new Affordable Care Act. But state CHIP directors may also be thinking about a slightly older benefit provision–the CHIPRA dental mandate. NASHP, in conjunction with the Children’s Dental Health Project, recently completed an issue brief for the National Maternal and Child Oral Health Policy Center on states’ dental benefit changes as a result of CHIPRA, and the findings may help state CHIP programs that are still mulling over their options, state officials working on the EHB, and advocates focused on ensuring strong coverage for children.
Prior to CHIPRA, all states voluntarily offered some level of oral health benefit, but benefits varied widely by state. CHIPRA leveled the playing field by requiring all states to offer dental coverage that meets a minimum level. Although regulations are still forthcoming, CMS guidance gives states two options. States may offer a state-defined benefit package with coverage of services in ten distinct categories such as diagnostic and preventive care and orthodontics. Or, similar to the options the federal government gave states with CHIP and the EHB package, states may offer a benchmark plan. Benchmark options include:
1. The Federal Employee Health Benefits Program dependent dental coverage that employees selected the most frequently in the past two years;
2. State employee dependent dental coverage that employees selected the most frequently in the past two years; or
3. The state dental plan with the largest commercial, non-Medicaid enrollment.
However, unlike CHIP benefit packages and EHB, benchmark plans must truly be equivalent and not just actuarially equivalent. States may add benefits to the benchmark plans, but they may not subtract or alter the benefits that the benchmark plan provides. On the flip side, if the benchmark plan does not cover a certain service, such as orthodontics, the state is not required to cover it in its CHIP plan.
Of the nine states with CMS-approved State Plan Amendments (SPAs) at the time the brief was written, seven of nine chose to offer state-defined dental benefit packages as opposed to benchmark packages. This is perhaps surprising because states opting for state-defined coverage must cover costlier services such as orthodontics that may not be required with a benchmark package. Also, these states must cover medically necessary care that is in excess of annual benefit maximums. However, it may actually be less costly for states to provide a state-defined package, since the benchmark packages generally require hefty cost sharing, and CHIP cost sharing is limited to five percent of a family’s income, including non-dental services, too. So, it could be rather costly for a state to provide a benchmark plan with very limited cost sharing.
The new EHB guidance gives states two options for providing pediatric dental coverage–the Federal Employees Dental and Vision Insurance Program dental plan with the largest enrollment or the benefit package in the state’s CHIP program. While we don’t yet know the nuances of what this means, the apparent possibility of overlap in kids’ dental benefits across CHIP and EHB coverage gives state agencies a great opportunity to collaborate and ensure a level of consistency across coverages. For states that haven’t yet selected a CHIP dental benefits package, the EHB bulletin provides an incentive for collaboration, and for CHIP programs that have already implemented their CHIP dental benefits, it gives state officials working on the EHB a great resource to call on!
Benefits are only one part of improving children’s dental health, and states are looking forward to the release of the State Health Official letter regarding CMS’ oral health strategy to improve utilization rates. But CHIPRA’s dental benefit is a great start for children in CHIP, as it ensures that all CHIP kids have a base level of comprehensive oral health benefits needed for strong dental and physical health and well-being.