The AAPD, the American Dental Association, and other members of the Organized Dentistry Coalition (ODC) commented to the federal Center for Consumer Information and Insurance Oversight (CCIIO) on Jan. 31, 2012, in response to draft guidance from this agency on essential health benefits (EHB). ODC commented that the benchmark plans identified in the guidance fall short of finding the proper balance between affordability and ensuring a comprehensive set of pediatric oral health benefits for the EHB package. ODC urged HHS to address the pediatric oral health benefit in a separate guidance, and suggested this additional guidance include more specific criteria for determining if the benchmark plan chosen by the state is in line with the typical employer-sponsored plan currently offered in the dental benefits market. ODC also recommended that benchmark plans include state requirements for general anesthesia for dental services in 2016 and beyond.
The Affordable Care Act (ACA) requires that all insurance issuers in the individual or small group markets- inside or outside of state insurance exchanges- must cover "essential health benefits", including pediatric oral care. This must be "equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary." Under the ACA’s directive, the Secretary of Labor conducted survey of employer-sponsored coverage to determine the benefits typically covered.
The Dept. of Labor report of April 15, 2011 included the following discussion of pediatric oral health coverage:
" . . . Plans typically grouped dental services into categories, such as preventive services (typically exams and cleanings), basic services (typically fillings, dental surgery, periodontal care, and endodontic care), major services (typically crowns and prosthetics), and orthodontia. Cost sharing for dental services typically involved an annual deductible—the median was $50 per person. After meeting the deductible, dental plans often paid a percent of covered services up to a maximum annual benefit. The median percent paid by the plan was 100 percent for preventive services, 80 percent for basic services, and 50 percent for major services and orthodontia. The median annual maximum was $1,500; a separate maximum applicable to orthodontic services also had a median value of $1,500."
On December 16, 2011, CCIIO issued an Essential Health Bulletin indicating that states will be permitted to selected benchmark plans, defined as: the largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market; any of the largest three state employee health benefit plans by enrollment; any of the largest three national Federal Employee Health Benefit Plan (FEHBP) options by enrollment; or the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the state. If the pediatric oral health benefit is missing from the chosen benchmark plan, a state must supplement the benchmark to cover the EHB category with one of the following options: the Federal Employees Dental and Vision Insurance Program (FEDVIP) dental plan with the largest national enrollment; or the state’s separate Children’s Health Insurance Program (CHIP). This was confirmed in a FAQ document issued by the CMS Center for Medicaid and CHIP Services on February 17, 2012.
During the transitional years of 2014-2015, if a state chooses a benchmark plan that is subject to existing state benefit mandates, those mandates would be included in the EHB package, obviating the requirement that the state defray the cost of the mandates. If the state selects a benchmark that does not include some or all of the mandates, the state would have to pay for those mandates not covered by the benchmark. For 2016 and beyond, the agency will develop an approach that might exclude some state benefit mandates from the EHB package.
For the CMS FAQ document of February 17, 2012, and a link to the CCIIO essential health benefits bulletin of December 16, 2011, click here.