ADEA Washington Update

Pediatric Dental Care Provision Under the Affordable Care Act Faces Challenges

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Parents may not be required to buy dental coverage if the cost of the stand-alone dental coverage does not count toward the amount of financial assistance a family could receive to purchase health insurance. And, if bought as a separate policy, the kids' dental coverage will require payments in addition to those for medical coverage. Many worry that the added expense puts this out of reach for many parents. In other words, families who do not qualify for Medicaid or the Children’s Health Insurance Program may not be able to afford pediatric dental coverage.

ediatric dental care is one of the Affordable Care Act’s (ACA) 10 “essential benefits,”3 broad categories of care that many insurers must cover starting in 2014. Under the ACA, children's dental coverage must be included in most health plans offered in the individual or small group insurance markets, or be available to consumers to purchase as supplemental policies.

In federally run exchanges, or those in which states are partnering with the federal government, stand-alone dental policies can include out-of-pocket costs as high as $700 per child or $1,400 per family. (State-run exchanges can set their own "reasonable" out-of-pocket limits.) These expenses are in addition to what the families would pay for medical coverage.

For plans sold on the federal exchanges, all medically necessary dental services are covered without cost-sharing once a family has spent -- not including premiums -- $700 in dental costs ($1,400 if there are two children or more). Families with children who have severe dental issues may find that number easier to reach than the out-of-pocket maximum for a family medical policy, which can be as high as $12,700 in 2014.

"This is a huge disappointment," said Sen. Ben Cardin (D-MD), a longtime proponent of access to dental care who is leading the effort to revise current health law regulations for pediatric dental services. "This is inconsistent with the philosophy of the Affordable Care Act."

3. Beginning in 2014, the Affordable Care Act requires non-grand fathered health plans to cover essential health benefits (EHB), which include items and services in the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care. The essential health benefits should be equal in scope to a typical employer health plan.

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