Catching Up on Dental Coverage for Kids

By Joe Touschner

Marketplaces are now open and families are comparing plans so it’s a good time to focus on where we stand on dental coverage and link to a couple of helpful resources from the Children’s Dental Health Project and Community Catalyst.

As we’ve known since the Affordable Care Act was signed into law, pediatric dental coverage is part of the essential health benefits.  But will all children covered by new plans have affordable access to dental care?  Answering the question remains complicated, because dental coverage policies vary by state and insurance market and are continuing to evolve.

Families who buy coverage in the marketplaces will have the choice of purchasing a stand-alone pediatric dental plan in addition to any health plan they buy.  In many states, families will have the alternative choice of purchasing a health plan that integrates dental benefits, so the family will face one premium and one set of cost-sharing amounts for all categories of benefits.  But some state marketplaces may not offer these “embedded” products in 2014.

Whether it makes sense for a family to purchase a stand-alone plan or an embedded benefit depends on a number of factors.  Embedded plans can take advantage of the premium tax credits and cost-sharing reductions available for eligible families from the federal government.  Stand-alone plans generally won’t have these kinds of federal subsidies.  But another issue for families to consider is how cost-sharing is structured.  In an embedded plan, families may need to meet a deductible that applies to both medical and dental benefits—since a combined deductible is likely to be high, some families may not spend enough for the plan to start paying benefits.  So families will need to consider their expected health costs and how they relate to the cost-sharing that will be required under their different options, in addition to the post-tax credit premium charges.  (A side note on cost-sharing, we now know the overall cap for stand-alone plans’ cost sharing in most marketplaces:  In federally facilitated marketplaces, it will be $700 for one child or $1400 for multiple children.  State marketplaces can set their own reasonable limits, with a $1000 cap most common among those I’ve seen reported.)

As I mentioned in the April blog post, families who purchase coverage in the individual and small group markets outside of marketplaces will effectively face a requirement to buy pediatric dental coverage due to federal rules.  Yet there is no federal requirement for families who buy coverage through the marketplace to purchase pediatric dental coverage.  However, at least two states have chosen to establish a requirement to purchase in their own marketplaces—so in some states there won’t be an inside/outside the marketplace difference where this policy is concerned.  More states are considering marketplace pediatric dental requirements and we may see more of them for 2014 or 2015.  Advocates for children should consider these requirements carefully—they can be a good way to bring dental coverage to more children.  At the same time, requiring low-income families to purchase a product whose affordability remains uncertain can be problematic.

Given all these considerations for families, many who buy in the marketplace will need reliable advice in choosing a dental plan.  As navigators and other assisters prepare to serve families, the Children’s Dental Health Project has offered to provide technical assistance to aid navigator organizations and other assisters.

Finally, another great resource from CDHP and partners at Community Catalyst is a short brief that highlights the issues of affordability, access, consumer protections, and robustness of benefits for kids’ dental coverage under the ACA.