Dental care for children was supposed to be one of the basic benefits that all health insurance plans would have to cover under the Affordable Care Act.
But a change in the rules means that the coverage is now optional and that many families will have to pay extra if they want dental plans for their kids.
“It was originally included as one of 10 essential healthcare benefits, but it seems to have evolved into being a ‘non-essential’ essential benefit,” said Arthur Meisel, executive director of the New Jersey Dental Association.
When the law was approved in 2010, it listed pediatric dental care as an “essential” benefit.
But last year, when the federal Department of Health and Human Services explained how the ACA would actually be implemented, the agency issued a rule allowing insurance companies in New Jersey and most other states to leave out pediatric dental coverage.
Dental coverage has almost always been offered through separate, stand-alone insurance plans,rather than directly by medical insurers.
Some of those same dental insurers lobbied to be allowed to sell their stand-alone plans on the new healthcare exchanges, a right they won in an amendment sponsored by Sen. Deborah Stabenow, a Michigan Democrat.
However, the amendment did not require federal subsidies to help people pay for the stand-alone dental plans, which could have increased the cost of the ACA law. In addition, the amendment could have resulted in low-income Americans being hit with a tax penalty for not buying separate dental coverage for their kids, despite the lack of subsidies.
So the HHS decided that, in states like New Jersey that use the federal healthcare exchange, parents would face no penalties if they didn’t buy pediatric dental plans, effectively making the coverage optional.
The decision to separate out pediatric dental also followed lobbying by insurance companies that wanted to keep premiums affordable while including the range of benefits required by the law.
“It's the age-old question of comprehensiveness versus affordability,” said Wardell Sanders, president and CEO of the New Jersey Association of Health Plans. “There's certainly a strong case for folks having dental coverage, and dental health is clearly connected to your physical health. It does cost more money to have the dental benefits, too.”
Meisel said the impact on how many people will sign up for pediatric dental coverage is still unclear. Dental insurer United Concordia, which operates nationwide, says it has sold “several thousand” plans in the state so far.
“We’ve actually seen the greatest enrollment for us in the New Jersey marketplace,” said Kurt Shook, the company’s director of core partnerships. “We’ve seen a lot of interest in New Jersey for pediatric, and frankly our adult stand-alone dental products as well.”
Healthcare experts said many lower-income families who need subsidies will not be affected because they will be directed to NJ FamilyCare, which provides Medicaid and Children’s Health Insurance Program coverage, and includes dental insurance for all participants.
NJ FamilyCare covers children in families that earn up to 350 percent of the federal poverty level, which amounts to $82,425 a year for a family of four. Under the ACA’s Medicaid expansion, the program also covers adults with income below 138 percent of the poverty level, or $31,322 for a family of four.
However, no help is available for families who earn more than 350 percent of the federal poverty level. For example, a family of four earning $83,000 would have to pay at least $672 a year, in addition to their medical premiums, for dental coverage for two children on New Jersey’s exchange, based on the lowest-cost policies offered.
“NJ Family Care is one package of coverage, and pediatric dental is there,” Sanders said. “So I think a lot of this discussion is probably more about folks in higher income brackets than lower income brackets.”
Federal subsidies to buy health insurance are available to families with income below 400 percent of the poverty level, which amounts to $94,200 for a family of four. But under an IRS rule issued last year, the subsidy calculation, which depends on both income and the cost of insurance, does not consider the added cost of stand-alone dental plans.
When the ACA was being crafted, health advocates pushed for pediatric dental coverage. Tooth decay is the most common chronic childhood disease, and untreated cavities can cause pain, school absences, difficulty concentrating and other problems. In rare cases, untreated dental problems have contributed to deaths of children.
Under New Jersey’s rules, dental plans for children up to age 19 cover the full cost of oral exams and cleanings twice a year. They also offer full or partial coverage of x-rays, fluoride treatment, fillings, root canals, extractions and emergency care. Orthodontics are generally covered only if deemed medically necessary. Benefits are based on the benchmark plan selected by the state, in this case the NJ FamilyCare CHIP plan.
By 2018, an additional 181,000 children in New Jersey could gain dental coverage compared to the number enrolled in 2010, according to projections by the American Dental Association. About 66,000 of those would have coverage purchased through the exchange and 34,000 through NJ Family Care. Another 81,000 would gain coverage as their parents obtain dental coverage through employer-sponsored health insurance.
While the law does not mandate adult dental coverage, expanded Medicaid does provide dental insurance for all participants, and other adults are expected to voluntarily buy coverage. Some 201,000 more adults could have dental insurance by 2018, with 181,000 enrolling in NJ Family Care and 19,000 getting insurance through the exchange, according to the ADA.
Insurers are allowed to offer pediatric dental benefits embedded in their medical plans, but those in the marketplace for New Jersey do not, instead offering add-on coverage or allowing customers to opt for stand-alone dental plans. AmeriHealth New Jersey, one of the three insurers offering medical plans in the marketplace, sells coverage provided by United Concordia at an additional charge.
“We’re giving people the choice to enable them to make the best selection for them, and for them to have an understanding of what the costs are,” said Mike Munoz, AmeriHealth’s senior vice president for sales and marketing.
Stand-alone dental plans for children that are offered by United Concordia and Dentegra cost $28 to $51 a month on the marketplace, with more expensive plans covering a greater portion of costs or offering additional benefits, according to data from Healthcare.gov. The companies also offer adult dental coverage.
On their own websites the insurers offer less expensive dental plans, which are not certified to be sold on the exchange and may have less generous benefits, fewer in-network dentists or other differences. For example, AmeriHealth offers one stand-alone United Concordia plan for $14 a month.
Insurers say allowing stand-alone dental plans in the exchanges preserves competition, giving consumers options other than their medical insurer’s offering.
But the decision to not include the cost of pediatric dental in subsidy calculations has drawn fire from legislators and insurers, who have asked the federal government to change the policy.
“That would certainly make the dental benefits more affordable for more Americans, so we're very supportive of that effort,” Shook said. “There have been conversations with various parties to encourage the IRS to do that.”
One other nuance of the law, which Shook called a “drafting error” in the ACA, has also caused confusion, even among experts on the legislation.
Americans are not required to buy stand-alone dental plans, according to the HHS. But when insurers sell policies off-exchange — as AmeriHealth and others do on their websites — they are required to offer pediatric dental. And if a parent buying a plan off-exchange declines to buy pediatric dental at the same time, the parent must give the insurer “reasonable assurance” that he or she is buying the dental coverage elsewhere.
It is unclear whether that means the parent has to provide the medical insurer with a copy of the pediatric dental policy, or is allowed to fib about having bought it elsewhere. The state Department of Banking and Insurance did not immediately respond to an email requesting clarification.
Seton Hall University health law professor John V. Jacobi, who has testified before the state Legislature on legal issues related to the ACA, described the pediatric dental coverage situation as “a mess.”