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Covering pediatric dental benefits Date: 09/05/13


Chad Terhune

By Mary Otto

Pediatric dental benefits are among the 10 essential health benefits included in the Patient Protection and Affordable Care Act.

But offering them on the new health insurance marketplaces scheduled to open Oct. 1 holds challenges for states. Should kids’ dental benefits be sold as standalone plans, separate from medical insurance as they usually are? Should they be bundled with other benefits? Embedded into policies? Is everyone required to buy them? Are parents required to buy them? Will they be affordable?

As I wrote in a recent blog post, Chad Terhune of the Los Angeles Times has done a good job of writing about the complexities of fitting pediatric dental benefits into California’s exchange, “Covered California.”

He was good enough to share his insights into the unfolding story and to offer advice to AHCJ members who might want to see how this issue is playing out in their own states.

The Covered California story is huge and it has an amazing number of moving parts. How did the need for a piece focusing on pediatric dental benefits come to your attention? When you started asking questions about how your state exchange was handling kids dental benefits, what did you learn?

I think it’s really a neglected issue in terms of the rush to roll out these exchanges and all these different health plans. A lot of the focus is on basic health insurance but it was always in the background here in California. And I had not been paying a lot of attention to it but then it became a pretty heated debate among regulators, patient advocates children’s groups over how the California exchange was handling it.

And as a reporter I needed to educate myself about what is going on here.

One of the first things we all hear about essential health benefits is that there are ten things that every plan must cover. But I soon learned you can be an essential health benefit but not be required … it’s not really 10. It’s 9.5.

Oral health and children’s advocates were very excited that pediatric dental benefits were included among the 10 essential health benefits. But you are finding in California that kids dental benefits are not quite there like the essential health benefits, are they?

It’s strange. To have something that’s essential but not required. And that’s kind of peeling the onion on the federal health law. You find out all these nooks and crannies and things that we, as reporters, need to understand and then we have to try to turn around and boil it down for the average reader.

California was left with “how do we offer this to consumers?” That started another interesting debate. Do you include it in every single policy and spread the cost against everybody? You have a lot of people who will never use a pediatric dental benefit. They don’t even have children. You think of people who pay taxes for schools and their kids are grown up and they might grumble: “I’m getting no benefit for this. Why am I paying?” Or do you just have standalone dental benefits for families that want this, make them pay for it. And you really had two distinct camps here and both had very compelling arguments.

The third thing that happened was that it became a timing issue, They kind of ran out of time to do it a different way because everybody is kind of rushing to get this done. In the end they went with the standalone plan.

After hearing from children’s advocates who wanted to see the dental benefits embedded, you wrote that Covered California exchange officials announced they would revisit the issue and look at making changes to how pediatric dental benefits are offered on the exchanges in 2015. What happens next?

It’s the case now where 2014 is right around the corner. There is not a lot you can change right now in terms of getting out bids, getting responses, having insurers figure out how they would do it, pricing, getting a network. That’s complicated. And its been hard enough just to get the basic health plans in order. So the idea is now, “Look we can’t do everything for 2014. We are going to get the basics. And then we are going to revisit this in the coming months to try to do something for 2015.”

I think the dental benefits are really neglected and are not written about a lot. And if you look at the data it’s an important issue, obviously for parents. In terms of health care for kids it’s a big issue in terms of tooth decay, in terms of missing school. But then you have the question of the cost. And what can we afford. And the big thing for the exchanges has been affordability. They are trying to keep down these premiums as much as possible. You start adding benefits, it increases costs.

And advice for reporters who want to dive into this story in their own states? Where to start? What to look for? How to unravel this?

First, I would just go to the exchange and ask “How are you handling dental plans?” You can have standalone. You can have them embedded as part of the basic health plan, which is a very different idea; usually they are separate. Or you can bundle them. So say “What are you offering? The standalone? Can you bundle the two together? Or is it embedded? Is it part of the basic health plan?” And then kind of take it from there on their response. And then look at what it would cost. Is it $10 a month for a dental plan? Is it $20? Look at what the options would be for an average consumer. Then the larger questions down the road would be whether they would require people to buy dental benefits. Right now you’ve got pediatric dental as an essential health benefit but it’s not required for kids. Not required for adults. But I think there are some policymakers who are saying down the road we would not only require health [benefits], we would require dental [benefits] of some form. But that’s down the road.