A dental working group at the District of Columbia Health Benefit Exchange Authority has published a dental options report that illustrates some of the choices exchange builders are making.
The Patient Protection and Affordable Care Act (PPACA) requires federal regulators to work with officials in the District of Columbia and all 50 states to set up exchanges, or Web-based health insurance supermarkets, for individuals and small groups by Oct. 1.
Each plan sold in an exchange is supposed to offer coverage for an “essential health benefits” (EHB) package. PPACA requires the package to include pediatric dental benefits.
Jurisdictions can decide whether to set up their exchanges or have the federal government do the job. The District of Columbia is setting up its own exchange.
The U.S. Department of Health and Human Services (HHS) has decided that the carriers that sell medical insurance through an exchange need not include the pediatric dental benefits in the benefits package if exchange users can also use the exchange to buy stand-alone dental plans that include the required pediatric dental benefits.
The HHS secretary has said that a stand-alone dental plan sold through an exchange can offer coverage for adults, if an exchange and its regulators allow that.
“D.C. law does not require it,” the D.C. working group said in its report.
The working group said all of its members agreed that insurers selling stand-alone pediatric dental plans through the exchange should also be able to sell non-pediatric dental benefits.
The working group said one controversy concerns “reasonable out-of-pocket maximums” — or the total amount an enrollee can spend on deductibles, co-payments and coinsurance amounts for in-network care each year.
Federal regulators have suggested that a $1,000 out-of-pocket dental plan maximum would be considered reasonable, the working group said.
Maryland has set its dental out-of-pocket maximum at $1,000 if there is one child in a dental plan, and $2,000 if there are two or more children in the plan.
Dental insurers like the idea of having a $1,000-per-child out-of-pocket maximum and are predicting that about 2 percent of children will reach the limit, the working group said.
About 4 percent of the children would reach the limit if the maximum were set at $500, the working group said.
“One reason for the low percentages is that only medically necessary orthodontia is covered as an EHB, and according to the experts, the handicapping criteria to reach that threshold are extremely difficult,” officials said. “A pediatric dentist reported that children who reach the threshold have significant deformities.”
Many consumer advocates think a $1,000 per child maximum is too high, the working group said.
Actuaries have suggested that reducing the maximum to $270, from $1,000, might cost just $2 to $3 in premiums per child, but critics have disagreed with that estimate, the working group said.