Pediatric coverage lacks ‘true mandate’

The Affordable Care Act (ACA) lists pediatric services, including dental and vision care, among the 10 essential health benefits (EHB) that all qualified health plans (QHP) must cover starting this year.  

Traditionally, in the commercial market, both dental and vision coverage have been offered in the form of stand-alone insurance products that consumers can purchase in addition to major medical plans. However, dental and vision coverage is often integrated into public plans such as Medicaid and state Children’s Health Insurance Plans. 

In developing the implemention regulations for the ACA, administrators at the Department of Health and Human Services (HHS) had a decision to make: Should pediatric dental and vision care be covered as a fully integrated benefit in QHPs or in the form of stand-alone plans?

The National Association of Dental Plans and National Association of Vision Care Plans argued that stand-alone plans would be less disruptive to the market, easier for consumers to understand and would better allow patients to maintain existing relationships with their established care providers.

However, the American Optometric Association (AOA) and American Dental Association (ADA) noted that fully integrated dental and vision care benefits in medical plans are subject to a range of consumer protections that may not apply to stand-alone insurance products.

 In the end, HHS administrators rendered a split decision with all QHPs required to cover pediatric vision care as a fully integrated benefit. Exchange plans were allowed to cover pediatric dental care as either an integrated or add-on benefit.

That option has become a legal loophole that enables parents to opt out of pediatric dental coverage, according to the ADA.

Preliminary HHS data suggest as few as one in five children with ACA health policies may have dental coverage this year.

Pediatric dental benefit

QHP pediatric dental coverage generally includes preventive services such as teeth cleaning,  X-rays, fillings and orthodontics considered medically necessary; however, the exact benefits vary from state to state.

HHS regulations give QHPs the option to offer pediatric dental coverage in three forms:

• Embedded coverage in medical plans;

• Stand-alone dental plans (SADPs); or

• Bundled products that pair a medical and a dental policy.

However, no states offered bundled pediatric dental benefits for the 2014 plan year.

Most marketplaces offered both embedded coverage plans and SADPs this year, but a few state-based exchanges, such as Connecticut’s, offered only embedded pediatric coverage, and Nevada, Washington and California offered only stand-alone products in the individual market, according a report by the National Academy for State Health Policy (NASHP), an organization of state health policy makers.

Under the regulations, each state has the discretion to make the purchase of pediatric dental benefits mandatory, and a few states have, such as Washington and Kentucky. However, the federal marketplace does not. 

Click to enlargeA report by ADA cited that HHS data for the 36 states served by the federal marketplace and also California show that the average take-up rate for children who selected a medical plan and also a SADP is 15.9%. In the states where pediatric dental benefits are not available through SADPs-Arkansas, California, Mississippi, Montana, New Jersey, New Mexico and Utah-the average take-up rate is 26.7%.

Data are not yet available on the number of children who have enrolled in plans with embedded pediatric dental coverage through the federal marketplace, nor is data from state exchanges on either SADPs or embedded coverage plans.

However, the preliminary HHS data were enough to prompt some cautionary research briefs from the ADA Health Policy Institute.

“Overall, the take-up rate of stand-alone dental plans for children is low when compared to the objectives of the Affordable Care Act,” authors Cassandra Yarbrough and Marko Vujicic, PhD, say in in the most recent ADA brief. “Although further analysis is needed based on full enrollment data, early results suggest the lack of a true mandate for pediatric dental benefits within the health insurance marketplaces is having important consequences.”

The SADP take-up rate for children varies widely among states, from 0.0%  in Alabama to 31.9% in Idaho, according to HHS. 

Low SADP take-up rates are not unique to those under age 18. Overall, the take-up rate for SADPs in the marketplace is just 20%, according to HHS. That means only 1,129,739 of the 5,446,178 individuals who obtained coverage through the federal marketplace opted for dental coverage.

Lack of a mandate for adult dental coverage under the ACA has effectively served to discourage interest in coverage for children, the ADA believes.

“Dental is treated differently from other essential health benefits, creating unique implementation challenges,” says an NASHP report.

According to the report, federal regulations exclude SADPs from several key ACA provisions designed to ensure coverage that is affordable for low-income Americans.

Cost-sharing reductions designed to help mitigate out-of-pocket spending are also not applicable to SADPs. Additionally, dental plans may have a separate out-of-pocket maximum stacked on top of the out-of-pocket spending limit for a medical plan.

The NASHP report also references a confusing consumer experience. Many state exchange websites provide relatively little information on dental benefits.  Navigators may have trouble explaining pediatric dental coverage, particularly in states that offer a choice of embedded and SADP options.

Pediatric vision benefit

While hard data on the pediatric vision benefit have not yet been released by HHS, anecdotal evidence suggests primary eye care practitioners around the country are already seeing an increase in pediatric patients, according to AOA. The association contends that full integration of pediatric vision care into the QHP better reflected Congress’ intention to cover a wide range of vision care and eye health services for children.

Under the ACA, health plans offered through state exchanges must provide full coverage of childhood routine, fully dilated eye exams, as well as follow-up care and eyeglasses or contact lenses necessary to correct refractive errors. Initially, the law was meant to provide coverage for child and adolescent vision screenings during wellness visits only; however, coverage was expanded to include complete exams and additional benefits in the wake of intense lobbying by AOA.

The association contends that federal officials designed the benefit specifically to help ensure that all children undergo comprehensive eye exams. The association cites studies showing that simple screenings fail to detect serious eye health and vision problems in almost 50% of children. Those problems can range from eye conditions such as pediatric glaucoma, cataract or eye cancer, to ocular manifestations of systemic conditions such as diabetes.

With most screenings focusing largely on determining whether a child has adequate visual acuity (distance vision), a host of other possible vision problems may not be detected, including amblyopia or strabismus, which can lead to learning problems. However, the American Academy of Ophthalmology (AAO), American Academy of Pediatrics (AAP) and American Association for Pediatric Ophthalmology and Strabismus (AAPOS) continue to encourage parents to have their children screened for vision problems, then follow up with comprehensive eye exams if screening results warrant them. 

The organizations specifically recommend vision screening be conducted in a pediatrician’s office as part of a wellness visit, although screenings at a school, health center or health fair may be sufficient. The AAP, however, contends that vision screenings should occur in the context of a medical home.

Although vision screenings provide an effective way to encourage childhood wellness visits, only 50% of infants undergo such visits, according to the AAP. To help spot developmental vision problems, wellness visits for newborns and children up to three years old should include a red reflex test, corneal light reflection, ocular motility, pupil examination, external examination and vision assessment, the AAP says.

Changes for 2015

The ADA Health Policy Institute research briefs suggest a number of fixes should be pursued at the state and federal level to ensure dental coverage for children. However, ADA spokespersons are guarded about what specific steps the association is taking.

With support from the DentaQuest Foundation, a nonprofit organization supporting and promoting oral health, NASHP held a meeting with state and federal marketplace officials, dental stakeholders and national experts in January to identify major issues in delivering dental benefits through marketplaces and potential policy and program solutions. A report presents findings from the meeting but notes they were not unanimous.

Delta Dental and other dental plans say many of the reported problems regarding tax credits and deductibles are the result of HHS adopting some, but not all, of their recommendations on utilization of SADPs. They call for the agency to revisit their entire package of recommendations.

At the request of the ADA and other dental groups, the Internal Revenue Service recently clarified its policies regarding tax credits for SADPs. However, the ADA has asked for further guidance, calling those clarifications inadequate.

In March, the Centers for Medicare and Medicaid Services issued a final rule lowering the dental out-of-pocket cost for plan year 2015 to $350 for one child and $700 for two or more children. Similarly, a 2013 law in California caps out-of-pocket spending across medical and dental benefits at a single level beginning in plan year 2015.

Some stakeholder groups have also developed dental-specific training information to assist exchange navigators during the next open enrollment period for 2015 coverage, according to NASHP. 

Ed Moody, M.D., president of the American Academy of Pediatric Dentistry, says the most significant issue to address is mandating the purchase of pediatric dental coverage, whether it’s an embedded plan or SADP. 

“We also recommend that embedded plans have a separate dental deductible,” he says. “These changes would make this essential health benefit work for children.” 

Bob Pieper is a freelance healthcare writer based in St. Louis.