1. The ACA Pediatric Dental Benefit: Issues for Consumer Assisters and Oral Health Stakeholders in Region VIII to Consider Colin Reusch Senior Policy Analyst Children’s Dental Health Project The materials and opinions presented are that of the speaker and do not represent the opinions and/or position of the U.S. Department of Health and Human Services and that of the Health Resources and Services Administration.

2. 2 OVERVIEW: ORAL HEALTH & DENTAL BENEFITS

3. 3 Overview: Oral Health Oral health is essential to overall health and impacts: –Nutrition –Learning –Social development –Employment More than half of new military recruits are unfit for deployment as a result of dental disease.

4. 4 Overview: Oral Health Tooth decay remains the #1 chronic condition among children –Caused by the disease, dental caries –Bacterial and can be transmitted mother to child –“Silent epidemic” – Surgeon General –But easily preventable

5. 5 Overview: Oral Health Tooth decay is 4 times more prevalent than asthma, affecting: –nearly half of five year olds; –and more than two-thirds of adolescents Takes hold early in life Kids who see dentists by age 2 less likely to experience tooth decay Can be prevented and managed with early intervention and: –Fluoride, good nutrition, and healthy habits About 1 in 7 kids and adolescents lack dental coverage (MEPS).

6. 6 Overview: Dental Benefits Not traditionally a true insurance product –Most often has an annual dollar limit on coverage (avg. = $1,200) Most often separate from medical insurance or “stand-alone” Cost-sharing (amount patient pays out-of-pocket) varies by category of services, example of typical dental benefits structure: Dental ServicesMember PaysPlan Pays Preventive & Diagnostic (cleanings, x-rays, fluoride treatments, sealants) 0%100% Minor Restorative (fillings, crowns, simple extractions) 20%80% Major Restorative (root canals, gum surgery, implants, dentures, wisdom tooth extraction) 50% Orthodontics (braces, etc.)50%

7. 7 DENTAL BENEFITS UNDER THE ACA: ESSENTIAL HEALTH BENEFITS (EHB)

8. 8 Coverage: what Congress intended Expand dental coverage to nearly all children Make dental coverage an integral part of kids’ coverage Improve quality and affordability of dental care Make prevention-focused, science-based practice a priority Bridge the gaps between medical and dental care & providers Systematically bolster & improve the entire oral health care system

9. 9 Essential Health Benefits (EHB) Covered by plans in: –New health insurance exchanges –Small group insurance market –Individual insurance market 10 broad categories of covered services Specific services not outlined State-selected benchmark plans dictate covered services If benchmark did not include pediatric dental state must supplement with either: –CHIP or FEDVIP dental benefit

10. 10 EHB: Pediatric Dental Benefit Category 10: “Pediatric services, including oral and vision care” Part of a comprehensive children’s benefit Stand-alone dental plans may provide Exchange coverage If a stand-alone participates, Qualified Health Plans (QHPs) exempt from oral care requirement Statute treats dental benefits differently when they are provided through a stand-alone dental plan vs. a QHP.

11. 11 EHB: Dental Benefits ACA reforms to pediatric dental benefits: –Makes it part of essential health benefits (EHB) Offered in Marketplaces (exchanges) and small group/individual insurance markets in each state –Attempts to subsidize through premium tax credits –Limits cost-sharing (out-of-pocket maximums) –Removes annual and lifetime dollar limits on coverage (children only) –Requires offering of child-only plans (up to age 19) –Limits orthodontic coverage to medically necessary

12. 12 Where States Stand

13. 13 QUESTIONS?

14. 14 EHB DENTAL BENCHMARKS

15. 15 EHB Supplemental Dental Benchmarks Federal Employees Dental and Vision Insurance Program (FEDVIP) –Comprehensive dental coverage, based on MetLife High plan. –Chosen by MT, SD, WY Children’s Health Insurance Program (CHIP) –Typically comprehensive but varies by state –Chosen by ND, CO *Utah chose a state employee benefit plan with limited pediatric dental and did not supplement with FEDVIP or CHIP

16. Dental Benchmarks & MN Ortho © National Association of Dental Plans Green Green = State CHIP program (24), MN Ortho covered except where pattern Blue Blue = FEDVIP (25 plus DC), Carrier Defined MN Ortho OrangeOrange = Dental benefit in medical EHB (1), pattern indicates no MN Ortho As of 10.31.13

17. 17 How Children Get Dental Coverage Under the ACA Overview Source: Colin Reusch and Joe Touschner. Pediatric Dental Benefits Under the ACA: Issues for State Advocates to ConsiderPediatric Dental Benefits Under the ACA: Issues for State Advocates to Consider

18. 18 EHHB: Dental Benefits How is dental coverage available in the new marketplaces? For Children: –ACA allows stand-alone dental plans to offer pediatric dental portion of EHB “either separately or in conjunction with a qualified health plan [QHP]” –Insurers must offer child-only plans –“High” and “Low” options available: Actuarial Value (AV) of 85% and 70% respectively For Adults: –Adult dental coverage may be available but is not part of the EHB No tax credit available Traditional dental insurance with dollar limits

19. 19 EHB: Dental Benefits How are dental benefits be offered in the marketplaces? Pediatric Essential Health Benefits Qualified Health Plan (QHP) Stand-Alone Dental QHP Including Dental

20. 20 EHB: Dental benefits Must pediatric dental benefits be purchased? If pediatric dental benefits are offered through a stand-alone dental plan, QHPs are not required to but may provide such coverage. Stand-alone dental plans are not required to be purchased unless state policy dictates otherwise. Outside of the marketplaces, QHPs must have “reasonable assurance” that enrollees have purchased pediatric dental.

21. 21 EHB: Dental Benefits Stand-alone Optional to purchase (unless state requires) Separate insurance policy & premium Separate deductible Separate out-of-pocket maximum Adult coverage may be part of some plans No cost-sharing reductions Some consumer protections may not apply QHP w/ Embedded Dental Dental benefits part of health plan (QHP) One premium for health and dental May have unified deductible or separate deductible for dental Individual or family plan includes dental for children; some plans may include adult dental Cost-sharing reductions apply All consumer protections apply

22. 22 Out-of-Pocket (OOP) Maximums ACA limits how much individuals/families can pay out-of-pocket Qualified Health Plan: $6,350 for individual $12,700 for family Reduced for incomes up to 400% FPL Stand-alone dental plan: $700 per child (FFM) $1,400 for 2 or more children (FFM) State-based marketplaces may set their own standard

23. 23 EHB: Dental Benefits How are dental benefits offered in Region VIII? StateStand-alone dental plans QHPs with embedded dental Colorado*Yes MontanaYesNo North DakotaYes South DakotaYes UtahYesNo WyomingYes *State-based marketplace

24. 24 REGION VIII DENTAL PLAN EXAMPLES

25. 25 Example: SD Delta Dental Silver Pediatric Stand-Alone Dental Plan 100%: Type I - Diagnostic & Preventive50%: Type II - Routine Restorations Routine examinations - two per coverage year. Routine dental cleaning (prophylaxis) - two per coverage year. Bitewing x-rays - two per coverage year. Full mouth/panoramic x-rays - one in any five-year interval. Fluoride applications - two per coverage year. Space maintainers (fixed, band type) on primary posterior teeth up to age 14. Dental sealants - once for unrestored 1st and 2nd permanent molars of children up to age 16. Silver (amalgam) fillings, and tooth-colored (composite) fillings. If a tooth colored filling is used to restore back (posterior) teeth, benefits are limited to the amount paid for a silver filling. 50%: Type III - Extractions, Root Canals, Periodontal Disease, Crowns, Bridges, Dentures, and Implants 50%: Orthodontics Crown buildups/posts. Pre-formed or stainless steel restorations. Root canals. Relines, repairs and recementations. Treatment of diseases of the tissues supporting the teeth. Crowns when teeth cannot be restored with another filling material. Extractions and other oral surgery. Emergency treatment for relief of pain. Bridges, partial dentures, complete dentures, and implants. Medically necessary treatment for the proper alignment of teeth. See handbook for definition of “Medically Necessary Orthodontic Treatment”. Deductible: $50 per child per coverage year. The deductible does not apply to orthodontic services. OOP Max: $700 per child, $1400 per two or more children

26. 26 Example: WY BestOne Pediatric Stand-Alone Dental Plan In-NetworkOut-of-Network Diagnostic & Preventive Services Plan covers 100%Plan covers 60% Basic ServicesPlan covers 55%Plan covers 40% Major ServicesPlan covers 35%Plan covers 20% Medically Necessary Orthodontics Plan covers 50% Deductible: $50 per child per coverage year. Applies to preventive out of network, basic and major services in or out of network. OOP Max: $700 per child, $1400 per two or more children

27. 27 Example: CO HealthOP Bobcat PPO (QHP with embedded dental) In-NetworkOut-of-Network Pediatric Dental ServicesPlan covers 100%Plan covers 0% Oral examLimits 2 visitsNot covered Fluoride applicationsLimit 2 applicationsNot covered X-raysLimit 1 setNot covered CleaningLimit 1 cleaningNot covered SealantsLimit 1 per tooth per yearNot covered FillingsLimit 1 fillingNot covered Simple extractionsLimit 1 extractionNot covered CrownsLimit 1 crownNot covered Deductible: $6,350 individual or $12,700 family. Deductible applies to all dental services. OOP Max: $6,350 individual or $12,700 family. OOP max applies to all dental services.

28. 28 WY WINhealth (QHP with embedded dental) ServiceBronze or Silver Gold or Platinum Limits & Exceptions Preventive Dental Services 100% Exams and/or Prophylaxis once every six months; Fluoride treatment once every twelve months; Sealants on posterior permanent teeth once every three years. Basic Dental Services60%80% Bitewing x-rays once every six months; Full Mouth X-rays limited to once every five years; Synthetic restorations (white fillings) on posterior (back) teeth are optional and are payable as an amalgam (silver filling) benefit. Major Dental Services50% Pre-authorization is required on oral surgery and it must also meet the Delta Dental of Wyoming definition of medical necessity. Preauthorization is required on all crowns, bridges, dentures and implants. Orthodontics50% Preauthorization is required and must meet the Delta Dental of Wyoming definition of medical necessity. A two year waiting period is required on all orthodontics. Deductible: ranges from $4,000 for bronze plans to $750 for platinum plans. Deductible applies to all but preventive services. OOP Max: ranges from $6,350 for bronze plans to $1,500 for platinum plans. Applies to all medical and dental services.

29. 29 Example: UT BestOne Stand-Alone Pediatric Dental Plan 100%: Diagnostic & Preventive Services Routine oral exam Cleanings Fluoride treatment X-rays Sealants 50%: Orthodontic Services (30% out of network) Diagnosis and treatment for repair of cleft palate, severe craniofacial defects or injury impacting function of speech, swallowing or chewing. Deductible: $75 per child per coverage year. Applies to preventive out of network & all basic and major services. OOP Max: $700 per child, $1400 per two or more children

30. 30 What is ideal dental coverage? Pediatric dental coverage should: Cover the full range of dental services a child or adolescent needs, including medically- necessary orthodontics. Pose little or no barrier to accessing basic preventive services. Be affordable. Have adequate provider networks. Avoid undue delay of care.

31. 31 DENTAL PLAN EXAMPLES OUTSIDE REGION VIII

32. 32 Connecticut Pediatric Dental Options: Embedded Dental ServicesMember Pays (Bronze) Member Pays (Silver) Member Pays (Gold) Member Pays (Platinum) Preventive & Diagnostic 0% Basic Restorative40% 20%40% Major Restorative50% 40%50% Orthodontic (medically Necessary) 50% Family Deductible$6,350*$6,000$2,000$0 *Deductible applies to all but Preventive & Diagnostic Services (Bronze only)

33. 33 Dental ServicesMember Pays (Standard Option) Member Pays (High Option) Preventive & Diagnostic0% Basic Restorative40%20% Major Restorative50%40% Orthodontic (medically Necessary) 50% Deductible (per child up to 3 children)* $75$50 Out-of-Pocket Max (per child / for multiple children $700 / $1,400$300 / $600 Connecticut Pediatric Dental Options: Stand-Alone *Deductible does not apply to preventive and diagnostic services

34. 34 Areas of Concern in Region VIII Utah – very limited dental services in most plans Colorado – no orthodontic coverage in dental EHB benchmark Region-wide – transparency in embedded pediatric dental benefits –Summary of benefits does not usually provide adequate detail on dental coverage (see handout)

35. 35 QUESTIONS?

36. 36 PLAN STRUCTURE AND CONSUMER ASSISTANCE

37. 37 Choosing Dental Coverage Factors to consider –Covered services –Plan cost-sharing structure –Out-of-pocket (OOP) maximums –Cost-sharing reductions –Deductibles –Premium rates –Availability of tax credits –Consumer protections

38. 38 Covered Services, Cost-sharing, & Deductibles State-selected EHB defines what services must be covered. Cost-sharing (how much the plan pays for specific services) may vary from plan to plan Some plans may have different deductibles

39. 39 Covered Services, Cost-sharing, & Deductibles Example Only Plan APlan B Service FrequencyMember pays Plan paysFrequencyMember pays Plan pays Cleanings2x/year0%100%4x/year0%100% X-Rays1x/year0%100%2x/year0%100% Sealants1x/3 years per tooth 0%100%1x/3 years per tooth 0%100% Fillings4x/year40%60%No limit*20%80% OrthodonticsN/A*50% N/A*50% Deductible$50$75 *After deductible is met

40. 40 Covered Services, Cost-sharing, & Deductibles Example Only Stand-Alone Dental Plan QHP with Embedded Dental Service CategoryPlan Pays Preventive & Diagnostic90%100%* Basic Restorative55%80%* Major Restorative35%*60%* Orthodontics50%* Deductible$50$2,000 *Deductible must be met before plan covers services

41. 41 Covered Services, Cost-sharing, & Deductibles Take-aways: Plans in a state cover the same services Cost-sharing & deductibles varies by plan Consumers should understand how much they are expected to pay for services High deductibles can be a barrier to care

42. 42 ACA sets limits on out-of-pocket expenses (OOP maximums) –OOP maximums vary by income up to 400% FPL ACA regulations allow for a separate OOP maximum for stand-alone dental plans –In addition to medical OOP maximum –Does not vary by income –Federal Standard: $700 per child/$1,400 multiple children –State marketplaces can set their own standard If dental benefits are part of QHP, medical OOP maximum applies to all benefits Out-of-Pocket Maximums

43. 43 Out-of-Pocket Maximums Example Family of 4 Income as % FPL OOP Maximum (QHP with embedded Dental) OOP Maximum QHP Only OOP Maximum Stand-Alone Dental Total OOP Max QHP + Stand- Alone Dental 255%$6,350 $1,400$7,750 350%$8,466 $1,400$9,866

44. 44 Out-of-Pocket Maximums Take-aways: Stand-alone dental plans have a separate OOP maximum in addition to OOP maximum for QHPs Stand-alone dental OOP maximum does not vary according to income Consumers should understand whether meeting the QHP OOP maximum for dental is an affordability barrier for them

45. 45 QUESTIONS?

46. 46 Premium Tax Credits Dental Benefits and Premium Tax Credits The ACA subsidizes the purchase of EHB coverage through premium tax credits Available to individuals & families earning up to 400% FPL Tax credits are paid to insurers on behalf of enrollees. The ACA states that the tax credit is applicable to pediatric dental benefits regardless of how they are purchased. Tax credit goes first to health plan (QHP); any remaining tax credit is then paid to stand-alone dental plan.

47. 47 Premium Tax Credits How is the tax credit calculated? Based on the second-lowest cost silver health plan in the marketplace If this plan does not cover pediatric dental, the tax credit will be based only on the cost of health services The cost of stand-alone pediatric dental coverage is not included in this calculation Families purchasing silver-level health coverage and stand-alone pediatric dental coverage will likely not have any tax credit available to support the purchase of dental coverage.

48. 48 Premium Tax Credits Example: Montana family of 4 w/ annual income of $70,650 –Expected annual premium contribution= $6,712 (9.5% of income) –2 nd lowest cost silver plan (no dental) = $7,694 –Tax credit: $7,694 – 6,712 = $982 –Dental premium (2 kids) = $528 –Total premium obligation = $7,240 (10.3% of income)

49. 49 Premium Tax Credits Take-aways: Tax credits are based on the cost of the second lowest cost silver plan in the marketplace. If no QHPs in the marketplace include pediatric dental, the tax credit amount is based only on the cost health coverage. Consumers should understand that there may not be enough tax credit to cover the cost of stand-alone dental coverage.

50. 50 QUESTIONS?

51. 51 OTHER AREAS OF INTEREST AND CONCERN

52. 52 Consumer Protections The ACA includes numerous market reforms for all benefits provided through a QHP. The ACA removes annual and lifetime dollar limits on coverage for stand-alone dental plans. The following do not apply to benefits provided through a stand-alone dental plan: –Protection against denials for pre-existing conditions –Guaranteed issue/renewal –Fair insurance premiums (based only on age and geography) –Right to external appeals process

53. 53 Network Adequacy The ACA requires that all plans in the marketplace have an adequate provider network but standards for dental plans are vague. Consumers should review available plan information to make sure preferred providers in their area are included in the network: –Prospective patients may need to call dentists offices in their area to find one in their network –The insurance plans should also be able to provide a list of providers

54. 54 Network Adequacy Consumers may also look to Essential Community Providers (ECPs) such as: –Federally qualified health centers (FQHCs) –Ryan White providers –Family planning providers –Indian providers –Specified hospitals (Disproportionate Care Hospitals, Children’s Hospitals, Rural Referral Centers, Sole Community Hospitals, Critical Access Hospitals) “ECPs include providers described in section 340B of the PHS Act and section 1927(c)(1)(D)(i)(IV) of the Social Security Act.”

55. 55 Network Adequacy Plans in the Federally-Facilitated Marketplaces must include at least 20% of available ECPs in the service area in their network and: –All available Indian providers in the services area –At least one ECP in each of the categories described on the previous slide in each county in the service area where available. Plans may be able to meet a lower expectation of 10% inclusion of ECPs if justification is provided to CMS.

56. 56 Network Adequacy Take-aways: Plans must have adequate networks but measurement of adequacy is not clear for dental Essential Community Providers (ECPs) must be included in plan networks in FFMs. Consumers should understand what types of providers are available to them in when purchasing dental coverage

57. 57 RECAP: WHAT CONSUMERS NEED TO KNOW

58. 58 Recap: What Consumers Need to Know How pediatric dental benefits will be available to them How dental benefits work and how plans differ (services, plan structure, cost-sharing, deductibles) The financial impact of their choice of dental benefits (OOP maximums, cost-sharing reductions, premium rate differences, tax credit amount and applicability) Consumer protections available to them What providers are available to them

59. 59 YOUR ROLE: DEMYSTIFICATION AND SURVEILLANCE

60. 60 Your Role Navigators/Assisters: Serving as a resource to consumers, helping to demystify dental coverage State Oral Health Programs: Serving as a resource to state stakeholders, applying your dental expertise Health and Dental Plans: Marketing, public education, additional plan information, further consumer assistance training, tracking enrollment State Dental & Primary Care Associations: Helping providers understand the ACA’s dental coverage landscape, noting network adequacy issues, helping consumers understand payment State Oral Health Coalitions: Coordinating & Collaborating to identify issues and bring together key stakeholders on improving implementation

61. 61 Your Role What questions should we ask? Are consumers purchasing coverage? How can providers, insurers, & other stakeholders collaborate to maximize enrollment? What is the consumer/family experience like? What barriers are consumers encountering? Are provider networks sufficient? Are ECPs included in dental plan networks? Are children getting treatment? What needs to change in order to achieve better oral health outcomes (state-based marketplaces have more flexibility in decision-making)?

62. 62 Questions? Colin Reusch, MPA creusch@cdhp.org 202.417.3595 http://www.cdhp.org